http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–3 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1018821
Crack abuse during pregnancy: maternal, fetal and neonatal complication J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Florida International University on 09/01/15 For personal use only.
Azar Aghamohammadi and Mandana Zafari Department of Midwifery, Sari Branch, Islamic Azad University, Sari, Iran
Objective: The aim of this study was to assess the effects of crack on pregnancy outcomes. Methods: We studied 88 crack user pregnant women in this study. These women were matched to a drug-free group (n ¼ 90) chosen from the population of the same hospital. Maternal outcomes including preeclampsia, placenta abruption, gestational diabetes and preterm labor, and neonatal complication including low birth weight and low Apgar score in 5 min were compared in crack using and drug-free groups. Data were analyzed by SPSS software. Chi-square test and Student’s t-test and Relative Risks (RRs) were used in this study. Results: The results of our study showed that crack abuse during pregnancy was associated with higher rate of preeclampsia p ¼ 0.003 (RR, 1.731; 95% CI, 1.777–2.545), placental abruption p ¼ 0.001 (RR, 2.439; 95% CI, 1.369–4.343), preterm labor p50.000 (RR, 3.249; 95% CI, 2.053– 5.141) and low birth weight p50.000 (RR, 2.179; 95% CI, 1.462–3.247). Conclusions: Crack abuse had significant influence on pregnancy outcomes. Crack appears to influence the prevalence of low birth weight, preterm labor, preeclampsia and placental abruption.
Crack, drug abuse, placenta abruption, preeclampsia, pregnancy outcome, preterm labor
Introduction Cocaine is an alkaloid obtained from the leaves of Erythroxylon coca that is a small tree native to South America .Cocaine, a stimulant and anesthetic agent, has been used for centuries. Crack is a form of cocaine that was found since 30 years ago. It is a more addictive form of cocaine . Crack is almost a pure highly concentrated cocaine obtained by converting the hydrochloride form back into the alkalinized form . The number of pregnant women who use crack is rising in society . The exact prevalence of crack use during pregnancy is not clear. Recent populations studied showed prevalence rate ranging from 1.8% to 18% [5,6]. Previous studies have found that maternal-crack use is related to intrauterine growth retardation [2,7], while others have found no relationship between crack use and neonatal growth . Many adverse pregnancy outcomes associated with crack use have been reported. These include fetal distress, stroke, sudden death, premature labor, placenta abruption, ruptured uterus, stillbirth, delivery of low birth weight infants and necrotizing enter colitis [7,9]. Singer et al.  found significant differences in the rate of stillbirths between women who abused only crack and a drugfree group. In contrast, the other researchers showed that Address for correspondence: Azar Aghamohammadi, Department of Midwifery, Sari Branch, Islamic Azad University, Sari, Iran. Tel: +98 9113514912. Fax: +98 1513267026. E-mail: azareaghamohamady @iausari.ac.ir
History Received 3 November 2014 Revised 24 December 2014 Accepted 10 February 2015 Published online 9 March 2015
crack user had not have a higher rate of placenta abruption than other women . Although the negative effects of crack on the adult users are well recognized, the potential impact of in uterus crack exposure is of substantial concern. Other studies have shown the effects of crack using in pregnancy and prenatal outcome but they are inconsequent because of methodological problems. The current study tries to improve the finding by the following points: (1) All women entered in our study are from public hospital admission and are not in addict treatment center. (2) Since crack users are generally polydrug users and previous studies assessed the effect of crack and other substances together, but in our study all women abused only crack and polydrug abuser were excluded in our study. (3) In the current study, we interviewed the women in delivery time and the women had continued their crack abuse during all of the pregnancy from the first to third trimester. The aim of this study was to highlight prenatal outcomes associated with cocaine use among pregnant women.
Methods From March 2011 to January 2014, we studied 267 crack using women enrolled for delivery in the labor ward of Imam Khomeini hospital in Sari, Iran. Each of these women had self-reported that they used crack in the first trimester of pregnancy. Sixty-seven percent of the women continued to use cocaine in whole of the pregnancy and urine exams were
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A. Aghamohammadi & M. Zafari
J Matern Fetal Neonatal Med, Early Online: 1–3
positive for them at the time of enrolling. In addition, we screened urine samples for opiates, amphetamines, barbiturates, marijuana, benzodiazepines, propoxyphene, phencyclidine, nicotine and ethanol by enzyme immunoassay methods. If urines for each crack using women were positive for other substances, we would exclude them from study, finally 88 pregnant women remained in our study. For evaluation of pregnancy outcomes of the crack user women, a drug-free control group (n ¼ 90) was chosen from the population of the prenatal center of Imam Khomeini Hospital and matched for education and income with comparison group. Comparison group mothers had not used drug before and urine samples for mentioned substances were negative and both samples had no prenatal care. The documents of all women were reviewed and labor and delivery data were recorded at the time of delivery. All neonates were examined at birth and their data were collected. Maternal outcomes including preeclampsia, placenta abruption, gestational diabetes and preterm labor, and neonatal complication including low birth weight and low Apgar score in 5 min were compared in crack-using and drug-free groups. Data was analyzed by SPSS software (Chicago, IL). Chisquare test and Student’s t-test and relative risks (RR) were used in this study.
Results Files of all samples were successfully evaluated. Maternal demographic characteristics are summarized in Table 1. Maternal age at delivery ranged from 18 to 36 years. The samples contained no high school graduates and 85% had low income. The maternal and neonatal complications in two group mothers are presented in Table 2. In our study, there is a statistically significant relation between crack using and preeclampsia, placenta abruption, preterm labor and low birth weight. There are no statistical differences in Apgar score in 5 min between the two groups.
Discussion The number of pregnant women who use crack is rising in society . Approximately 90% of cocaine user women are of Table 1. Maternal demographic characteristics. Maternal demographic Crack user women Drug-free women characteristics Mean ± SD Mean ± SD p value Age BMI Hemoglobin
24.88 ± 4.373 24.1 ± 2.06 12.6 ± 1.38
24.66 ± 4.423 23.25 ± 2.56 13/00 ± 1.47
0.479 0.67 0.718
reproductive age. Cardiovascular toxicity of cocaine is increased in pregnancy, and acute recreational cocaine abusing by pregnant women has been associated with prenatal complication . The research findings showed that 35% of crack user women had placental abruption, while this number was estimated as 14% in the drug-free group. 2 test showed that there would be a significant relation between crack using and placental abruption (p ¼ 0.001). Recent studies showed that cocaine use is intensely associated with placental abruption. The hypertensive effects of cocaine and the higher uterine contractility caused by higher norepinephrine levels lead to placental abruption [12–15]. Our findings showed that 61% of crack user women had preterm labor, while this number was estimated as 18% in the drug-free group. 2 test showed that there would be a significant relation between crack using and those suffering from preterm labor (p50.000). Recent studies indicated that preterm labor and delivery happen in 17–29% of all pregnancies among cocaine user [12,14,16] in comparison with the overall population risk of 5–10% . Eyler et al. showed that cocaine use in pregnancy leads to preterm labor and delivery . Animal studies indicated that cocaine increased plasma oxytocin concentration in a pregnant baboon . These findings showed that cocaine abuse can enhance uterine activity and this can describe the increased preterm labor prevalence in these women. Recent studies showed that women who cease cocaine use in the first trimester of pregnancy have been shown to have no increase in the risk of preterm delivery . This indicated that preterm delivery is not related to the chronic abuse of cocaine and cocaine using in the third trimester cause preterm birth. Our findings showed that 50% of crack user women had preeclampsia, while this number was estimated as 28% in the drug-free group. In our study, preeclampsia was defined as the association of hypertension (140/90 mmHg or more) plus proteinuria (4300 mg protein in the 24-h urine sample)  in the end of pregnancy. Because both samples (crack user and crack-free women) had no prenatal care and when they enrolled for delivery in the labor ward, they entered in our study, we did not have their blood pressure measurement before pregnancy and at first and second trimester and this is a limitation of our study. The 2 test showed that there would be a significant relation between crack using and those suffering from preeclampsia (p ¼ 0.003). Towers et al. showed that if a patient present in the third trimester with hypertension and clinical symptoms of
Table 2. Maternal and neonatal complications in crack user and drug-free mothers.
Pregnancy outcome Preeclampsia Placenta abruption Preterm labor Low birth weight Low Apgar in 5 min
Crack user women N (%) 44 31 54 49 11
(50%) (35%) (61%) (55%) (12%)
Dug-free women N (%) 26 13 17 23 13
(28%) (14%) (18%) (25%) (14%)
Relative risk (95% CI) (RR, (RR, (RR, (RR, (RR,
1.731; 2.439; 3.249; 2.179; 0.865;
95% 95% 95% 95% 95%
CI, CI, CI, CI, CI,
1.777–2.545) 1.369–4.343) 2.053–5.141) 1.462–3.247) 0.410–1.827)
8.311 10.328 33.478 16.76 0.144
0.003 0.001 0.000 0.000 0.437
Crack abuse and pregnancy complication
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preeclampsia that rapidly improve shortly after admission, cocaine intoxication should be considered as the possible source . Fox et al. indicated that preeclampsia and acute pulmonary edema can be caused by maternal cocaine use . Elevated levels of endothelin-1 may contribute to preeclampsia in women abusing crack . One unanticipated finding was that there are no statistical differences in Apgar scores in 5 min between two groups (p ¼ 0.437). In contrast the other researchers suggested that infants exposed to crack differ in orientation, motor processes, state regulation and number of abnormal reflexes from other population . Since the preeclampsia can cause preterm lung maturation, the lack of difference in Apgar scores can be explained . Our findings showed that 55% of crack user women had low birth weight, while this number was estimated as 25% in the drug-free group. 2 test showed that there would be a significant relation between crack using and those suffering from low birth weight (p50.000). Many studies showed that the incidence of intra uterus growth reduction (IUGR) and low birth weight among crack users is more than general population [16,27,28]. IUGR can be described by the periodical reduction in placental blood flow caused by vasoconstriction because oxygen and nutrient transfer to the fetus were decreased. Also maternal appetite was significantly destroyed by crack and this may lead to reduced maternal nutrition [29,30]. Crack abuse during pregnancy is a major difficulty in our society now. Crack abuse in pregnancy is accompanied with many adverse outcomes for both mother and baby. Finally, there are necessities for a strong screening to determine the crack users in pregnancy.
7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
19. 20. 21.
We thank Mrs. Jafari from Imam Khomeini hospital for helping us to do this study.
Declaration of interest
The authors report no declarations of interest.
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