Unrecognized “crack” cocaine abuse in pregnancy

Abstract

SummaryWe report a case of "crack" cocaine abuse in a pregnant patient associated with haematuria, proteinuria, haemolytic anaemia, renal impairment, thrombocytopenia and pulmonary oedema. The case illustrates the problems for clinicians where unrecognized cocaine abuse interferes with the diagnosis and management of a complicated pregnancy. In addition, we discuss the principles for the safe conduct of anaesthesia in the pregnant cocaine abuser. (Br. J. Anaesth. 1996;77:553-555) Key words Anaesthesia, obstetric. Complications, cocaine abuse. Pregnancy."Crack" cocaine abuse in pregnancy is well recognized in the USA. In the UK the level of awareness to this increasingly common problem needs to be improved 1 . This case illustrates the difficulties in differentiating the effects of cocaine abuse from the more usual complications of pregnancy. Cocaine has complex effects on many systems. It was not apparent until post-partum that the patient continued to abuse crack cocaine even while an inpatient. In retrospect the relationship between drug abuse and the course of her illness became clear.Crack cocaine abuse increases maternal morbidity, fetal morbidity and death [2][3][4] . It is likely that maternal crack cocaine abuse will be an increasing problem in the UK and at present the clinical effects may not be fully recognized. Case reportA 32-yr old, gravida 5, para 3, Afro-Caribbean woman presented to her general practitioner for antenatal assessment at 10 weeks' gestation. Her haemoglobin concentration was 10.1 g dl 91 and the blood film showed macrocytosis. Cervical and high vaginal swabs were infected with Gonococcus and Trichomonas. Her infection was treated and she attended again at 19 weeks' gestation when urinalysis showed moderate haematuria and mild proteinuria. Arterial pressure was 120/70 mm Hg.She did not attend again until 31 weeks' gestation when she complained of fatigue and dyspnoea on exercise. On physical examination her conjunctivae were pale, arterial pressure was 125/70 mm Hg and she had bilateral pitting oedema of the ankles. Cardiovascular and respiratory system examinations were otherwise unremarkable. Abdominal examination was consistent with a 31-week pregnancy with normal fetal heart sounds and movements. Urinalysis showed excessive blood and moderate protein. The full blood count result a week later showed haemoglobin 6.8 g dl 91, mean cell volume 110 fl and platelets 63 10 9 litre 91, and therefore hospital admission was arranged.In hospital, physical examination revealed an apical ejection systolic murmur. Deep tendon reflexes were normal. Her blood film showed a reticulocyte count of 4.9%. Serum creatinine concentration was 99 mmol litre 91 , which is high for a pregnant patient. Urea and electrolyte concentrations, liver function tests, uric acid and clotting screen were within normal limits. Autoimmune profile, lupus and platelet antibodies and haemosiderin were within normal limits but haptoglobin concentrations were low at 0.2 g litre 91. The 24-h urine volume was 2125 ml and p...