DRUGS IN PREGNANCY
MOTHERISK ROUNDS
Cocaine Abuse During Pregnancy Alex M. Cressman, MSc,1,2 Aniket Natekar, MSc,1 Eunji Kim, MHSc,1 Gideon Koren, MD,1,2 FRCPC, FACMT, Pina Bozzo, HBSc1 Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto ON
1
Faculty of Medicine University of Toronto, Toronto ON
2
Abstract Cocaine abuse during pregnancy is a significant public health problem but is infrequently discussed between physicians and patients. The impact of in utero cocaine exposure on pregnancy and the baby has received significant media attention in preceding decades because of fears of teratogenicity, long-term health consequences, and poor cognitive and neurodevelopmental outcomes. We sought to review the medical literature examining these phenomena. We identified risks to the pregnancy and baby in women abusing cocaine during pregnancy. These include preterm birth, placenta-associated syndromes (e.g., placental abruption, preeclampsia, and placental infarction), and impaired fetal growth. Long-term neurodevelopmental and cognitive deficits include (but are not limited to) poorer language development, learning and perceptual reasoning, behavioural problems, and adverse effects on memory and executive function. However, these results should be interpreted cautiously because cocaine abuse may be accompanied by many other maternal and sociodemographic risk factors, so it is difficult to ascertain the effect of cocaine alone. Therefore, it is critical to counsel patients about potential risk, and perhaps more importantly, to treat addiction and to better understand, and advocate for improvements to, these patients’ high-risk environment.
Résumé Bien que la consommation de cocaïne pendant la grossesse constitue un problème de santé publique considérable, elle ne fait que peu fréquemment l’objet de discussions entre les médecins et leurs patientes. Les effets de l’exposition in utero à la cocaïne sur la grossesse et l’enfant se sont mérités une attention médiatique considérable au cours des dernières décennies, en raison de préoccupations au sujet de la tératogénicité de la cocaïne, de ses conséquences à long terme sur la santé et de son influence sur l’obtention de piètres issues cognitives et neurodéveloppementales. Nous avons cherché à analyser la littérature médicale examinant ces phénomènes. Nous avons identifié des risques pour la grossesse et l’enfant attribuables à la consommation de cocaïne pendant la grossesse. Parmi ces risques, on trouve l’accouchement préterme, des syndromes associés au placenta (p. ex. décollement placentaire,
Key Words: Cocaine, pregnancy, teratogenicity Competing Interests: None declared.
628 l JULY JOGC JUILLET 2014
prééclampsie et infarctus placentaire) et l’altération de la croissance fœtale. Parmi les déficits cognitifs et neurodéveloppementaux à long terme, on trouve (entre autres) des difficultés quant au développement langagier, à l’apprentissage et au raisonnement perceptif, des problèmes comportementaux et des effets indésirables sur la mémoire et la fonction exécutive. Toutefois, ces résultats devraient être interprétés avec prudence, puisque la consommation de cocaïne pourrait s’accompagner de nombreux autres facteurs de risque maternels et sociodémographiques; il est donc difficile de déterminer l’effet qui est seulement attribuable à la cocaïne. Ainsi, il est d’une importance cruciale de conseiller les patientes au sujet des risques potentiels d’une telle pratique et, ce qui est peut-être encore plus important, d’assurer la prise en charge de l’assuétude et de mieux comprendre les conditions de vie à risque élevé de ces patientes (et de promouvoir la mise en œuvre de mesures permettant de les améliorer).
J Obstet Gynaecol Can 2014;36(7):628–631
BACKGROUND
C
anadian prevalence data are unavailable, but estimates from a 2012 survey conducted in the United States suggest that illicit drug use occurs in 5.9% of all pregnancies, with rates as high as 18.3% in 15- to 17-year-olds and 12.4% among 18- to 25-year-olds.1 Of these drugs, cocaine abuse has received media attention since the mid-1980s because of fears of teratogenicity, long-term health effects, and poor neurodevelopmental outcomes from in utero cocaine exposure.2–4 Cocaine is a highly addictive substance and is most often abused intranasally, but may also be smoked or injected. Abuse of cocaine is associated with a large number of health complications, including infectious disease, psychiatric illness, gastrointestinal complications, respiratory disease, and acute cardiovascular disease.5,6 Self-reported survey data from the United States suggest that cocaine use occurs in 1.1% of young adults aged 18 to 25 years.1 However, Canadian, United States, and European studies that have examined meconium
Cocaine Abuse During Pregnancy
and hair for cocaine and its metabolites suggest that rates of in utero cocaine exposure may be substantially higher (nearly 4- to 10-fold).7–9 Given that approximately 50% of all pregnancies are unplanned,10 fetal exposure may occur inadvertently before a woman knows she is pregnant. Cocaine rapidly crosses the human placenta11 and the fetal blood-brain barrier, and exhibits pharmacological activity in the developing fetal brain, where it is thought to interfere with neurotransmission and synaptic development.2,12 Notably, women who abuse cocaine may have other risk factors that contribute to adverse pregnancy and infant outcomes, including (but not limited to) lower socioeconomic status, inadequate prenatal care, polysubstance abuse, maternal infections, maternal psychopathology, and a history of partner violence (Table).13–19 Maternal cocaine abuse and in utero cocaine exposure therefore represent significant public health problems for both mother and fetus. EFFECT OF MATERNAL COCAINE ABUSE ON PREGNANCY OUTCOMES
Maternal cocaine abuse has been associated with a number of adverse pregnancy outcomes, including preterm birth, premature rupture of membranes, and a number of other placenta-associated syndromes (e.g., placental abruption, placental infarction, and preeclampsia).20–22 It has also been associated with intrauterine growth restriction leading to low birth weight and small for gestational age infants.18,20,21 An increased risk of miscarriage has been noted,23 but this association remains controversial. In a meta-analysis by Motherisk, polysubstance abusers who were also abusing cocaine had an increased risk of miscarriage compared with the reference group of drug-free mothers. However, when this analysis was completed with comparison of mothers who were abusing only cocaine with the drug-free control group, the effect was no longer observed.24 COCAINE IS NOT A GROSS STRUCTURAL TERATOGEN
Early reports by Bingol and colleagues suggested that cocaine may act as a teratogen.4 However, this study was limited in its assessment of confounding factors and had some methodological limitations.25,26 The contribution of other sociodemographic and environmental risk factors to the observed association was suggested as early as in 1987,25 amid growing fears of a potential epidemic of harm due to in utero cocaine exposure. In subsequent and more methodologically sound studies, no specific pattern of gross congenital anomalies or syndromes has been
Factors thought to confound the relationship between in utero cocaine exposure and pregnancy outcomes, infant growth, and long-term neurodevelopmental and cognitive deficits Confounding factors Ethnic minority status Lower socioeconomic status Polysubstance abuse Criminal history Homelessness Inadequate prenatal care Maternal undernutrition Maternal infections during pregnancy Maternal or childhood stress Parental or caregiver psychopathology Parental or partner violence Low birth weight Prematurity Residing in foster versus maternal care Low maternal intelligence Low maternal language ability Lower quality home and/or community environment Amount and duration of in utero cocaine exposure
identified.21,27,28 Therefore, it is thought that cocaine does not act independently as a gross structural teratogen. IN UTERO COCAINE EXPOSURE: GROWTH, COGNITIVE, AND NEURODEVELOPMENTAL OUTCOMES
Whether there is an effect of in utero cocaine exposure on long-term child growth remains uncertain. Studies have reported evidence of slower growth rates among prenatally exposed children up to the age of 10 years after other factors associated with child growth have been controlled for.15,28,29 Some studies have reported that children exposed to cocaine prenatally had adverse neurodevelopmental outcomes. Reported outcomes include, but are not limited to, poorer adolescent functioning,30 poorer perceptual reasoning,31 impairment in procedural learning,32 internalizing, externalizing, and total behaviour problems,33 more symptoms of oppositional defiant disorder and attention deficit hyperactivity disorder,34 impairment of executive function,19 adverse effects on short-term memory,35 and poorer language development.36,37 However, recent systematic reviews and meta-analyses suggest that sociodemographic, environmental, and other factors such as those listed in the Table may make a contribution to these adverse neurodevelopmental outcomes that is equal JULY JOGC JUILLET 2014 l 629
Drugs in Pregnancy
to or even greater than cocaine.19,38,39 Further, a recent study showed that environmental “protective factors,” such as resilience, caretaker involvement, higher family socioeconomic status, and family support and resources reduce the trajectory of behavioural problems from in utero cocaine exposure.16 COUNSELLING PATIENTS ON MATERNAL COCAINE ABUSE DURING PREGNANCY
Cocaine abuse has been associated with adverse pregnancy and fetal outcomes, but it most often occurs within the context of other social and environmental risk factors found in disadvantaged populations. Interventions aimed at managing maternal addiction and understanding the context in which drug abuse takes place, providing comprehensive prenatal care, reducing or discontinuing drug use, and improving the social determinants of health and environment in which pregnancy and infant development occur may help reduce risk to maternal and child health. Importantly, infants and children of cocaine-addicted mothers are at substantially higher risk for neglect and different types of abuse, and they need to be followed intensively to decide whether they can be adequately cared for by their biological parents. REFERENCES 1. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. 2. Behnke M, Smith VC. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics 2013;131(3):e1009–24. 3. Chasnoff IJ, Burns WJ, Schnoll SH, Burns KA. Cocaine use in pregnancy. N Engl J Med 1985;313(11):666–9. 4. Bingol N, Fuchs M, Diaz V, Stone RK, Gromisch DS. Teratogenicity of cocaine in humans. J Pediatr 1987;110(1):93–6. 5. Bhargava S, Arora RR. Cocaine and cardiovascular complications. Am J Ther 2011;18(4):e95–e100. 6. Glauser J, Queen JR. An overview of non-cardiac cocaine toxicity. J Emerg Med 2007;32(2):181–6. 7. Ostrea EM Jr, Brady M, Gause S, Raymundo AL, Stevens M. Drug screening of newborns by meconium analysis: a large-scale, prospective, epidemiologic study. Pediatrics 1992;89(1):107–13. 8. Pichini S, Puig C, Zuccaro P, Marchei E, Pellegrini M, Murillo J, et al. Assessment of exposure to opiates and cocaine during pregnancy in a Mediterranean city: preliminary results of the “Meconium Project.” Forensic science international 2005;153(1):59–65. 9. Forman R, Klein J, Barks J, Mehta D, Greenwald M, Einarson T, et al. Prevalence of fetal exposure to cocaine in Toronto, 1990-1991. Clin invest Med 1994;17(3):206–11.
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10. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011;84(5):478–85. 11. Schenker S, Yang Y, Johnson RF, Downing JW, Schenken RS, Henderson GI, et al. The transfer of cocaine and its metabolites across the term human placenta. Clin Pharmacol Ther 1993;53(3):329–39. 12. Benveniste H, Fowler JS, Rooney WD, Scharf BA, Backus WW, Izrailtyan I, et al. Cocaine is pharmacologically active in the nonhuman primate fetal brain. Proc Natl Acad Sci U S A 2010;107(4):1582–7. 13. Bendersky M, Alessandri S, Gilbert P, Lewis M. Characteristics of pregnant substance abusers in two cities in the northeast. Am J Drug Alcohol Abuse 1996;22(3):349–62. 14. Bauer CR, Shankaran S, Bada HS, Lester B, Wright LL, KrauseSteinrauf H, et al. The Maternal Lifestyle Study: drug exposure during pregnancy and short-term maternal outcomes. Am J Obstet Gynecol 2002;186(3):487–95. 15. Richardson GA, Goldschmidt L, Larkby C. Effects of prenatal cocaine exposure on growth: a longitudinal analysis. Pediatrics 2007;120(4):e1017–27. 16. Bada HS, Bann CM, Whitaker TM, Bauer CR, Shankaran S, Lagasse L, et al. Protective factors can mitigate behavior problems after prenatal cocaine and other drug exposures. Pediatrics 2012;130(6):e1479–88. 17. Nair P, Schuler ME, Black MM, Kettinger L, Harrington D. Cumulative environmental risk in substance abusing women: early intervention, parenting stress, child abuse potential and child development. Child Abuse Negl 2003;27(9):997–1017. 18. Bada HS, Das A, Bauer CR, Shankaran S, Lester B, Wright LL, et al. Gestational cocaine exposure and intrauterine growth: maternal lifestyle study. Obstet Gynecol 2002;100(5 Pt 1):916–24. 19. Lambert BL, Bauer CR. Developmental and behavioral consequences of prenatal cocaine exposure: a review. J Perinatol 2012;32(11):819–28. 20. Gouin K, Murphy K, Shah PS; Knowledge Synthesis group on Determinants of Low Birth Weight and Preterm Births. Effects of cocaine use during pregnancy on low birthweight and preterm birth: systematic review and metaanalyses. Am J Obstet Gynecol 2011;204(4):340 e1–12. 21. Addis A, Moretti ME, Ahmed Syed F, Einarson TR, Koren G. Fetal effects of cocaine: an updated meta-analysis. Reprod Toxicol 2001;15(4):341–69. 22. Mbah AK, Alio AP, Fombo DW, Bruder K, Dagne G, Salihu HM. Association between cocaine abuse in pregnancy and placenta-associated syndromes using propensity score matching approach. Early Hum Dev 2012;88(6):333–7. 23. Ness RB, Grisso JA, Hirschinger N, Markovic N, Shaw LM, Day NL, et al. Cocaine and tobacco use and the risk of spontaneous abortion. N Engl J Med 1999;340(5):333–9. 24. Lutiger B, Graham K, Einarson TR, Koren G. Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis. Teratology 1991;44(4):405–14. 25. Bauchner H, Zuckerman B, Amaro H, Frank DA, Parker S. Teratogenicity of cocaine. J Pediatr 1987;111(1):160–1. 26. Koren G. Cocaine and the human fetus: the concept of teratophilia. Neurotoxicol Teratol 1993;15(5):301-4; discussion 11–2. 27. Behnke M, Eyler FD, Garvan CW, Wobie K. The search for congenital malformations in newborns with fetal cocaine exposure. Pediatrics 2001;107(5):E74. 28. Minnes S, Robin NH, Alt AA, Kirchner HL, Satayathum S, Salbert BA, et al. Dysmorphic and anthropometric outcomes in 6-year-old prenatally cocaine-exposed children. Neurotoxicol Teratol 2006;28(1):28–38.
Cocaine Abuse During Pregnancy
29. Covington CY, Nordstrom-Klee B, Ager J, Sokol R, Delaney-Black V. Birth to age 7 growth of children prenatally exposed to drugs: a prospective cohort study. Neurotoxicol Teratol 2002;24(4):489–96. 30. Buckingham-Howes S, Berger SS, Scaletti LA, Black MM. Systematic review of prenatal cocaine exposure and adolescent development. Pediatrics 2013;131(6):e1917–36. 31. Singer LT, Nelson S, Short E, Min MO, Lewis B, Russ S, et al. Prenatal cocaine exposure: drug and environmental effects at 9 years. J Pediatr 2008;153(1):105–11.
35. Betancourt LM, Yang W, Brodsky NL, Gallagher PR, Malmud EK, Giannetta JM, et al. Adolescents with and without gestational cocaine exposure: longitudinal analysis of inhibitory control, memory and receptive language. Neurotoxicol Teratol 2011;33(1):36–46. 36. Landi N, Crowley MJ, Wu J, Bailey CA, Mayes LC. Deviant ERP response to spoken non-words among adolescents exposed to cocaine in utero. Brain Lang 2012;120(3):209–16.
32. Mayes L, Snyder PJ, Langlois E, Hunter N. Visuospatial working memory in school-aged children exposed in utero to cocaine. Child Neuropsychol 2007;13(3):205–18.
37. Nulman I, Rovet J, Greenbaum R, Loebstein M, Wolpin J, Pace-Asciak P, et al. Neurodevelopment of adopted children exposed in utero to cocaine: the Toronto Adoption Study. Clin Invest Med 2001;24(3):129–37.
33. Bada HS, Das A, Bauer CR, Shankaran S, Lester B, LaGasse L, et al. Impact of prenatal cocaine exposure on child behavior problems through school age. Pediatrics 2007;119(2):e348–59.
38. Ackerman JP, Riggins T, Black MM. A review of the effects of prenatal cocaine exposure among school-aged children. Pediatrics 2010;125(3):554–65.
34. Linares TJ, Singer LT, Kirchner HL, Short EJ, Min MO, Hussey P, et al. Mental health outcomes of cocaine-exposed children at 6 years of age. J Pediatr Psychol 2006;31(1):85–97.
39. Frank DA, Augustyn M, Knight WG, Pell T, Zuckerman B. Growth, development, and behavior in early childhood following prenatal cocaine exposure: a systematic review. JAMA 2001;285(12):1613–25.
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MOTHERISK ROUNDS
Cocaine Abuse During Pregnancy Alex M. Cressman, MSc,1,2 Aniket Natekar, MSc,1 Eunji Kim, MHSc,1 Gideon Koren, MD,1,2 FRCPC, FACMT, Pina Bozzo, HBSc1 Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto ON
1
Faculty of Medicine University of Toronto, Toronto ON
2
Abstract Cocaine abuse during pregnancy is a significant public health problem but is infrequently discussed between physicians and patients. The impact of in utero cocaine exposure on pregnancy and the baby has received significant media attention in preceding decades because of fears of teratogenicity, long-term health consequences, and poor cognitive and neurodevelopmental outcomes. We sought to review the medical literature examining these phenomena. We identified risks to the pregnancy and baby in women abusing cocaine during pregnancy. These include preterm birth, placenta-associated syndromes (e.g., placental abruption, preeclampsia, and placental infarction), and impaired fetal growth. Long-term neurodevelopmental and cognitive deficits include (but are not limited to) poorer language development, learning and perceptual reasoning, behavioural problems, and adverse effects on memory and executive function. However, these results should be interpreted cautiously because cocaine abuse may be accompanied by many other maternal and sociodemographic risk factors, so it is difficult to ascertain the effect of cocaine alone. Therefore, it is critical to counsel patients about potential risk, and perhaps more importantly, to treat addiction and to better understand, and advocate for improvements to, these patients’ high-risk environment.
Résumé Bien que la consommation de cocaïne pendant la grossesse constitue un problème de santé publique considérable, elle ne fait que peu fréquemment l’objet de discussions entre les médecins et leurs patientes. Les effets de l’exposition in utero à la cocaïne sur la grossesse et l’enfant se sont mérités une attention médiatique considérable au cours des dernières décennies, en raison de préoccupations au sujet de la tératogénicité de la cocaïne, de ses conséquences à long terme sur la santé et de son influence sur l’obtention de piètres issues cognitives et neurodéveloppementales. Nous avons cherché à analyser la littérature médicale examinant ces phénomènes. Nous avons identifié des risques pour la grossesse et l’enfant attribuables à la consommation de cocaïne pendant la grossesse. Parmi ces risques, on trouve l’accouchement préterme, des syndromes associés au placenta (p. ex. décollement placentaire,
Key Words: Cocaine, pregnancy, teratogenicity Competing Interests: None declared.
628 l JULY JOGC JUILLET 2014
prééclampsie et infarctus placentaire) et l’altération de la croissance fœtale. Parmi les déficits cognitifs et neurodéveloppementaux à long terme, on trouve (entre autres) des difficultés quant au développement langagier, à l’apprentissage et au raisonnement perceptif, des problèmes comportementaux et des effets indésirables sur la mémoire et la fonction exécutive. Toutefois, ces résultats devraient être interprétés avec prudence, puisque la consommation de cocaïne pourrait s’accompagner de nombreux autres facteurs de risque maternels et sociodémographiques; il est donc difficile de déterminer l’effet qui est seulement attribuable à la cocaïne. Ainsi, il est d’une importance cruciale de conseiller les patientes au sujet des risques potentiels d’une telle pratique et, ce qui est peut-être encore plus important, d’assurer la prise en charge de l’assuétude et de mieux comprendre les conditions de vie à risque élevé de ces patientes (et de promouvoir la mise en œuvre de mesures permettant de les améliorer).
J Obstet Gynaecol Can 2014;36(7):628–631
BACKGROUND
C
anadian prevalence data are unavailable, but estimates from a 2012 survey conducted in the United States suggest that illicit drug use occurs in 5.9% of all pregnancies, with rates as high as 18.3% in 15- to 17-year-olds and 12.4% among 18- to 25-year-olds.1 Of these drugs, cocaine abuse has received media attention since the mid-1980s because of fears of teratogenicity, long-term health effects, and poor neurodevelopmental outcomes from in utero cocaine exposure.2–4 Cocaine is a highly addictive substance and is most often abused intranasally, but may also be smoked or injected. Abuse of cocaine is associated with a large number of health complications, including infectious disease, psychiatric illness, gastrointestinal complications, respiratory disease, and acute cardiovascular disease.5,6 Self-reported survey data from the United States suggest that cocaine use occurs in 1.1% of young adults aged 18 to 25 years.1 However, Canadian, United States, and European studies that have examined meconium
Cocaine Abuse During Pregnancy
and hair for cocaine and its metabolites suggest that rates of in utero cocaine exposure may be substantially higher (nearly 4- to 10-fold).7–9 Given that approximately 50% of all pregnancies are unplanned,10 fetal exposure may occur inadvertently before a woman knows she is pregnant. Cocaine rapidly crosses the human placenta11 and the fetal blood-brain barrier, and exhibits pharmacological activity in the developing fetal brain, where it is thought to interfere with neurotransmission and synaptic development.2,12 Notably, women who abuse cocaine may have other risk factors that contribute to adverse pregnancy and infant outcomes, including (but not limited to) lower socioeconomic status, inadequate prenatal care, polysubstance abuse, maternal infections, maternal psychopathology, and a history of partner violence (Table).13–19 Maternal cocaine abuse and in utero cocaine exposure therefore represent significant public health problems for both mother and fetus. EFFECT OF MATERNAL COCAINE ABUSE ON PREGNANCY OUTCOMES
Maternal cocaine abuse has been associated with a number of adverse pregnancy outcomes, including preterm birth, premature rupture of membranes, and a number of other placenta-associated syndromes (e.g., placental abruption, placental infarction, and preeclampsia).20–22 It has also been associated with intrauterine growth restriction leading to low birth weight and small for gestational age infants.18,20,21 An increased risk of miscarriage has been noted,23 but this association remains controversial. In a meta-analysis by Motherisk, polysubstance abusers who were also abusing cocaine had an increased risk of miscarriage compared with the reference group of drug-free mothers. However, when this analysis was completed with comparison of mothers who were abusing only cocaine with the drug-free control group, the effect was no longer observed.24 COCAINE IS NOT A GROSS STRUCTURAL TERATOGEN
Early reports by Bingol and colleagues suggested that cocaine may act as a teratogen.4 However, this study was limited in its assessment of confounding factors and had some methodological limitations.25,26 The contribution of other sociodemographic and environmental risk factors to the observed association was suggested as early as in 1987,25 amid growing fears of a potential epidemic of harm due to in utero cocaine exposure. In subsequent and more methodologically sound studies, no specific pattern of gross congenital anomalies or syndromes has been
Factors thought to confound the relationship between in utero cocaine exposure and pregnancy outcomes, infant growth, and long-term neurodevelopmental and cognitive deficits Confounding factors Ethnic minority status Lower socioeconomic status Polysubstance abuse Criminal history Homelessness Inadequate prenatal care Maternal undernutrition Maternal infections during pregnancy Maternal or childhood stress Parental or caregiver psychopathology Parental or partner violence Low birth weight Prematurity Residing in foster versus maternal care Low maternal intelligence Low maternal language ability Lower quality home and/or community environment Amount and duration of in utero cocaine exposure
identified.21,27,28 Therefore, it is thought that cocaine does not act independently as a gross structural teratogen. IN UTERO COCAINE EXPOSURE: GROWTH, COGNITIVE, AND NEURODEVELOPMENTAL OUTCOMES
Whether there is an effect of in utero cocaine exposure on long-term child growth remains uncertain. Studies have reported evidence of slower growth rates among prenatally exposed children up to the age of 10 years after other factors associated with child growth have been controlled for.15,28,29 Some studies have reported that children exposed to cocaine prenatally had adverse neurodevelopmental outcomes. Reported outcomes include, but are not limited to, poorer adolescent functioning,30 poorer perceptual reasoning,31 impairment in procedural learning,32 internalizing, externalizing, and total behaviour problems,33 more symptoms of oppositional defiant disorder and attention deficit hyperactivity disorder,34 impairment of executive function,19 adverse effects on short-term memory,35 and poorer language development.36,37 However, recent systematic reviews and meta-analyses suggest that sociodemographic, environmental, and other factors such as those listed in the Table may make a contribution to these adverse neurodevelopmental outcomes that is equal JULY JOGC JUILLET 2014 l 629
Drugs in Pregnancy
to or even greater than cocaine.19,38,39 Further, a recent study showed that environmental “protective factors,” such as resilience, caretaker involvement, higher family socioeconomic status, and family support and resources reduce the trajectory of behavioural problems from in utero cocaine exposure.16 COUNSELLING PATIENTS ON MATERNAL COCAINE ABUSE DURING PREGNANCY
Cocaine abuse has been associated with adverse pregnancy and fetal outcomes, but it most often occurs within the context of other social and environmental risk factors found in disadvantaged populations. Interventions aimed at managing maternal addiction and understanding the context in which drug abuse takes place, providing comprehensive prenatal care, reducing or discontinuing drug use, and improving the social determinants of health and environment in which pregnancy and infant development occur may help reduce risk to maternal and child health. Importantly, infants and children of cocaine-addicted mothers are at substantially higher risk for neglect and different types of abuse, and they need to be followed intensively to decide whether they can be adequately cared for by their biological parents. REFERENCES 1. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. 2. Behnke M, Smith VC. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics 2013;131(3):e1009–24. 3. Chasnoff IJ, Burns WJ, Schnoll SH, Burns KA. Cocaine use in pregnancy. N Engl J Med 1985;313(11):666–9. 4. Bingol N, Fuchs M, Diaz V, Stone RK, Gromisch DS. Teratogenicity of cocaine in humans. J Pediatr 1987;110(1):93–6. 5. Bhargava S, Arora RR. Cocaine and cardiovascular complications. Am J Ther 2011;18(4):e95–e100. 6. Glauser J, Queen JR. An overview of non-cardiac cocaine toxicity. J Emerg Med 2007;32(2):181–6. 7. Ostrea EM Jr, Brady M, Gause S, Raymundo AL, Stevens M. Drug screening of newborns by meconium analysis: a large-scale, prospective, epidemiologic study. Pediatrics 1992;89(1):107–13. 8. Pichini S, Puig C, Zuccaro P, Marchei E, Pellegrini M, Murillo J, et al. Assessment of exposure to opiates and cocaine during pregnancy in a Mediterranean city: preliminary results of the “Meconium Project.” Forensic science international 2005;153(1):59–65. 9. Forman R, Klein J, Barks J, Mehta D, Greenwald M, Einarson T, et al. Prevalence of fetal exposure to cocaine in Toronto, 1990-1991. Clin invest Med 1994;17(3):206–11.
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