Abruptio Placentae Por Coca
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COCAINE INTOXICATION ASSOCIATED WITH ABRUPTIO PLACENTAE Delores Flowers, M D , John F.J. Clark, M D , a n d Lennox S . Westney, M D Washington, D C Acute cocaine intoxication h a s been associ- ated with elevated blood pressure a n d placen- tal abruption. A retrospective analysis w a s performed comparing gestational a g e a t t h e time o f placental abruption a n d response t o conventional therapy f or elevated blood pres- sure between patients known t o have ingested cocaine a n d those w h o were drug free. Data suggest that cocaine ingestion during nancy increases t h e risk o f early placental abruption a nd a n elevation o f blood pressure that i s n ot as responsive t o conventional therapy a s pregnancy-induced hypertension. Key words cocaine intoxication placental abruption cocaine abuse a n d pregnancy T h e increased popularity o f cocaine, once considered a harmless drug, has begun t o present itself a s a n obstetrical nightmare. According t o surveys, there a r e approximately 4 million t o 6 million current users o f cocaine, with a n estimated 5000 persons/day trying t h e drug fo r t h e first time. There i s n o stereotype of t he cocaine abuser. Cocaine u s e was once described as a social diversion f o r th e successful, well-educated, From t h e Department o f Obstetrics and Gynecology, Howard University Hospital, Washington, D C . Requests f o r reprints should be addressed t o D r John F.J. Clark, Department o f Obstetrics a nd Gynecology, Howard University Hospital, 2041 Georgia Ave, N W , Washington, DC 20060. upwardly-mobile professionals, but i t i s n o w t h e second-favored illicit drug after marijuana among high school students.1 2 T h e reason f or its newfound popular- i t y is thedecline i n the price o f t h e drug i n recent years. I n some urban markets, the price h a s dropped b y 3 0 . T h e ultimate high obtained by smoking freebase cocaine a n d t he relative inexpensiveness of crack cocaine have also le d t o i t s increased popularity. T h e u s e o f this during cause hyperten- sion that mimics pregnancy-induced hypertension, but does not respond t o conventional therapy. METHODS A N D MATERIALS All patients in t h e study presented i n labor a t th e Howard University Hospital labor a n d delivery suite, or a t a n affiliated hospital, between January 1988 and August 1988. Patients ages ranged from 1 6 t o 3 5 years. They were gravida 1 t o 4 andhadno t o full prenatal care. There were n o previous histories o f hypertension, a n d estimated a g e (EGA) was 28 t o 3 6 weeks. A l l patients w ho tested positive f o r cocaine b y blood a n d urine analysis, confirmed that they h a d ingested cocaine freebase or intravenous) 1 or 2 hours prior t o admission t o thehospital a n d onset of labor. Three of t h e 2 0 patients studied ar e presented, illustrating t h e difficulty i n separating this entity from preeclampsia. CASE REPORTS Case 1 A 21-year-old black woman presented a t 3 5 weeks after cocaine freebasing. S h e complained o f dizziness 2 3 0 JOURNAL OF TH E NATIONAL MEDICAL ASSOCIATION, VOL. 8 3 , NO. 3
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Transcript of Abruptio Placentae Por Coca
8/13/2019 Abruptio Placentae Por Coca
http://slidepdf.com/reader/full/abruptio-placentae-por-coca 1/3
COCAINE INTOXICATIONASSOCIATED WITH ABRUPTIOPLACENTAED e l o r e sF l o w e r s ,M D ,J o h n F . J .C l a r k ,M D ,a n d L e n n o xS . W e s t n e y ,MDW a s h i n g t o n ,DC
A c u t e c o c a i n e i n t o x i c a t i o nh a s b e e n a s s o c i -a t e d w i t h e l e v a t e d b l o o d p r e s s u r ea n d p l a c e n -t a l a b r u p t i o n . A r e t r o s p e c t i v e a n a l y s i s w a sp e r f o r m e dc o m p a r i n gg e s t a t i o n a l a g e a t t h et i m e o f p l a c e n t a l a b r u p t i o n a n d r e s p o n s et oc o n v e n t i o n a l t h e r a p yf o re l e v a t e d b l o o d p r e s -s u r e b e t w e e np a t i e n t s k n o w n t o h a v e i n g e s t e dc o c a i n e a n d t h o s e w h o w e r e d r u g f r e e .D a t as u g g e s t t h a tc o c a i n e i n g e s t i o n d u r i n g p r e g -n a n c y i n c r e a s e s t h e r i s k o f e a r l y p l a c e n t a la b r u p t i o n a n d a n e l e v a t i o n o f b l o o d p r e s s u r et h a t i s n o t a s r e s po n s i v e t o c o n v e n t i o n a lt h e r a p ya s p r e g n a n c y - i n d u c e dh y p e r t e n s i o n .
K e yw o r d s c o c a i n ei n t o x i c a t i o n p l a c e n t a la b r u p t i o nc o c a i n ea b u s ea n d p r e g n a n c y
T h e i n c r e a s e dp o p u l a r i t yo fc o c a i n e ,o n c ec o n s i d e r e da h a r m l e s sd r u g ,h a sb e g u n t o p r e s e n ti t s e l fa s a no b s t e t r i c a ln i g h t m a r e .A c c o r d i n gt o s u r v e y s ,t h e r ea r ea p p r o x i m a t e l y4 m i l l i o nt o 6 m i l l i o nc u r r e n t u s e r so f
c o c a i n e ,w i t h a n e s t i m a t e d5 0 0 0p e r s o n s / d a yt r y i n gt h ed r u g f o rt h ef i r s tt i m e .T h e r e i s n o s t e r e o t y p eo f t h ec o c a i n e a b u s e r .C o c a i n eu s e w a s o n c e d e s c r i b e da s as o c i a ld i v e r s i o nf o r t h e s u c c e s s f u l ,w e l l - e d u c a t e d ,
F r o mt h e D e p a r t m e n to f O b s t e t r i c sa n d G y n e c o l o g y ,H o w a r dU n i v e r s i t yH o s p i t a l ,Wa s h i n g t o n ,D C . R e q u e s t sf o r r e p r i n t ss h o u l d b e a dd r e s s e dt o D r J o h n F. J . C l a r k ,D e p a r t m e n to fO b s t e t r i c sa n d G y n e c o l o g y ,H o w a r dU n i v e r s i t yH o s p i t a l ,2 0 4 1G e o r g i aA v e ,N W ,Wa s h i n g t o n ,DC 2 0 0 6 0 .
u p w a r d l y - m o b i l ep r o f e s s i o n a l s ,b u t i t i s now t h es e c o n d - f a v o r e di l l i c i td r u g a f t e rm a r i j u a n aa m o n gh i g hs c h o o ls t u d e n t s . 12 T h er e a s o nf o ri t sn e w f o u n dp o p u l a r -i t yi s t h e d e c l i n ei n t h e p r i c eo ft h ed r u g i n r e c e n ty e a r s .I n s o m eu r b a nm a r k e t s ,t h e p r i c eh a s d r o p p e db y 3 0 .T h e u l t i m a t e h i g h o b t a i n e db y s mo k i n gf r e e b a s ec o c a i n e a n d t h e r e l a t i v ei n e x p e n s i v e n e s so f c r a c kc o c a i n e h a v e a l s ol e dt o i t s i n c r e a s e dp o p u l a r i t y .T h eu s e o f t h i sd r u g d u r i n gp r e gn a n cy c anc a u s e h y p e r t e n -s i o nt h a tm i m i c sp r e g n a n c y - i n d u c e dh y p e r t e n s i o n ,b u td o e sn o tr e s p o n dt o c o n v e n t i o n a lt h e r a p y .
METHODSAND MATERIALSA l lp a t ie n t s i nt h e s t u d yp r e s e n t e di n l a b o ra t t h e
H o w a r dU n i v e r s i t yH o s p i t a ll a b o ra n dd e l i v e r ys u i t e ,o ra ta n a f f i l i a t e dh o s p i t a l ,b e t w e e nJ a n u a r y1 9 8 8a n d A ug u s t1 9 8 8 .P a t i e n t sa g e sr a n g e df r o m 1 6t o 3 5 y e a r s .T h e yw e r eg r a v i d a1 t o4 a nd h a d n ot of u l lp r e n a t a lc a r e .T h e r ew e r en o p r e v i o u sh i s t o r i e so fh y p e r t e n s i o n ,a n de s t i m a t e dg e s t a t i o n a la g e ( E G A )w a s 2 8t o 3 6 w e e k s .A l lp a t i e n t sw h o t e s t e dp o s i t i v ef o r c o c a i n eb y b l o o d a n d u r i n ea n a l y s i s ,c o n f i r m e dt h a t t h e yh a d i n g e s t e dc o c a i n e f r e e b a s eo ri n t r a v e n o u s )1 o r2 h o u r sp r i o rt o a d m i s s i o nt ot h e h o sp i t a la n do n s e to fl a b o r .T h r e eo ft h e2 0 p a t i e n t ss t u d i e da r e p r e s e n t e d ,i l l u s t r a t i n gt h e d i f f i c u l t yi ns e p a r a t i n gt h i se n t i t yf r o mp r e e c l a m p s i a .
CASE REPORTSC a s e1
A 2 1 - y e a r - o l db l a c k w o m a n p r e s e n t e da t 3 5 w e e k sa f t e rc o c a i n e f r e e b a s i n g .S h e c o m p l a i n e do f d i z z i n e s s
2 3 0 JOURNAL OFTH E N AT I O N A LMEDICAL A S S O C I AT I O N ,V O L .8 3 ,N O .3
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COCAINE I N T O X I C AT I O N
a n d l o w e r a b d o m i n a lp a i n ,a n d d e n i e d r u p t u r eo fm e m b r a n e so r v a g i n a lb l e e d i n g .S h e h a d n o p r e n a t a lc a r e o r m e d i c a l i l l n e s s e s .H e r s o c i a lh i s t o r yw a s
s i g n i f i c a n tf o r c o c a i n e u s e d a i l yf o r 1 y e a r 1 . 7 5g m / d a y ) .On p h y s i c a le x a m i n a t i o n ,b l o o dp r e s s u r ew a s 1 7 0 / 9 9
mmHg; t h e h e a d a n d n e c ke x a m i n a t i o nw a s n o r m-o c e p h a l i ca t r a u m a t i c ,a n d p u p i l sw e r ec o n s t r i c t e d .B o t hb r e a s t sw e r e s o f t ,n o n t e n d e r ,a n d s y m m e t r i c a l .T h e r ew e r en o m a s s e so rd i s c h a r g e .T h e l u n g sw e r ec l e a r .T h ec a r d i o v a s c u l a rs y s t e mh a d n o m u r m u r s .T h e a b d o m e nw a s s o f t ,w i t h s t r o n gp a l p a b l ec o n t r a c t i o n sa n d t h ef u n d a lh e i g h tw a s 3 0 c m . T h e p e l v i ce x am in a t i o n w a ss i g n i f i c a n tf o r t h ee x t e r n a lg e n i t a l i ab e i n g w i t h i nn o r m a ll i m i t s ,t h ev a g i n a lc a n a lw a s p i n k a n d r u g u t e d ,w i t hn o l e s i o n s ,o rb l e e d i n g ,a n d t h ec e r v i xw a s 1 0 0
e f f a c e d ,4 cm d i l a t e d ,a n d m i n u s o n e s t a t i o n .T h ee x t r e m i t i e sw e r ew i t h i nn o r m a ll i m i t s .T h en e u r o l o g i c a le x a m i na t i o n w a ss i g n i f i c a n tf o r t h e p a t i e n tb e i n gs o m n o l e n t ,b u te a s i l ya r o u s e d .
T h e l a b o r a t o r yd a t aw e r e s ig n i f i c a n t f o ra w h i t eb l o o dc e l lc o u n t o f4 . 9cmm h e m o g l o b i no f9 . 7g m / d l ,h e m a t o c r i t o f2 9 , p l a t e l e t s1 6 8 cmm p r o t h r o m b i nt i m e o f 9 . 9 s e c o n d s ,t h r o m b o p l a s t i nt i m e o f 3 5 . 5s e c o n d s ,a n d f i b r i n o g e no f3 2 6 m g / d l .T h e i m p r e s s i o nw a s i n t r a u t e r i n ep r e g n a n c ya t 3 5 w e e k s b y d a t e s ,p r e - e c l a m p s i a ,a n d c h r o n i cc o c a i n ea b u s e .
T h e p a t i e n t sb l o o d p r e s s u r er a n g e w a s 1 8 5 t o 1 4 1m m H gs y s t o l i ca n d 1 1 1 t o9 2 m m H gd i a s t o l i c .T h ef e t a lm o n i t o r t r a c i n gw a s s i g n i f i c a n tf o r p e r s i s t e n tl a t ed e c e l e r a t i o n s .T h e p a t i e n tu n d e r w e n ta p r i m a r yc a e s a r -e a n s e c t i o nf o r f e t a ld i s t r e s sa n d d e l i v e r e da b o y ,w e i g h i n g1 4 1 7g r a m s ,w i t h a n A p g a rs c o r e o f o n e a t 1m i n u t e ,a n d f i v ea t 5 m i n u t e s .T h e p l a c e n t aw a s 2 0a b r u p t e d .P o s t o p e r a t i v e l y ,t h e p a t i e n tw a s p l a c e do nm a g n e s i u ms u l f a t ef o r 2 4 h o u r s .H y d r a l a z i n ea n dm e t h y l d o p aw e r eu s e d t o c o n t r o lb l o o dp r e s s u r e .
C a s e2A 2 1 - y e a r - o l db l a c k w o m a n ,g e s t a t i o n a la g e u n -
k n o w n ,w a s f o u n d i n a n a p a r t m e n to n t h ef l o o rw i t hb l o o d c o m i n gf r o mh e r m o u t ha f t e rh a v i n ga s e i z u r e .S h e w a s a dm i t t eda s J a n e Do e t o t h el a b o ra n d d e l i v e r ys u i te i na p o s t - i c t a ls t a t e .
On a d m i s s i o n ,p h y s i c a le x a m i n a t i o ns h o w e da b l o o dp r e s s u r eo f 1 7 0 / 1 1 0m m H g r a n g e :2 5 0 t o 2 1 0 s y s t o l i c ;1 2 0 t o 8 7 m m H gd i a s t o l i c ) ,p u l s ew a s7 0 b e a t s / m i n u t e ,a n d r e s p i r a t i o n sw e r e 2 0 b r e a t h sp e r m i n u t e .Ane c c h y m o t i ca r e a o v e rt h er i g h te y ea n d a t s w o l l e nu p p e rl i p w e r e a l s on o t e d .T h e l u n gf i e l d sw e r e c l e a r .T h ec a r d i o v a s c u l a re x a m i n a t i o nw a s w i t h i nn o r m a l l i m i t s .
T h e r e w e r en o p a l p a b l ec o n t r a c t i o n so n a b d o m i n a le x a m i n a t i o n .T h e f u n d a lh e i g h tm e a s u r e d3 7 cm a n df e t a lh e a r tt o n e sw e r e a u s c u l a t e da t 1 5 0 b e a t sp e r
m i n u t e .P e l v i ce x a m i n a t i o nr e v e a l e dt h ec e r v i xt o b e0 e f f a c e da n d n o t d i l a t e d .S i g n i f i ca n t l a b o r a t ov a l u e sw e r ew h i t eb l o o dc e l lc o u n t 1 2 . 9cmm h e m o g l o -b i n1 3g m / d l , h e m a t o c r i t3 8 . 6 p l a t e l e t s4 7 , 0 0 0cmmp r o t h r o m b i n9 . 7 s e c o n d s c o n t r o l :11 . 1 s e c o n d s ) ,t h r o m b o p l a s t i n2 7 s e c o n d s c o n t r o l :3 0 s e c o n d s ) ,a n df i b r i n o g e n1 9 0 m g / d l ; u r i n ed r u g s c r e e nw a s p o s i t i v ef o r c o c a i ne .C o m p u t e r i z e da x i a lt o m o g r a p h ys c a n o ft h eh e a d s h o w e dg e n e r a l i z e dc e r e b r a le d e m a .T h e i m p r e s -s i o nw a s i n t r a u t e r i n ep r e g n a n c ya t 3 7 w e e k sb y s i z e ,e c l a m p s i a ,a n d c o c a i n ea b u s e .T h ef e t a lm o n i t o rt r a c i n gw a s s i g n i f i c a n tf o rt h eo n s e to f f e t a lb r a d y c a r d i a ,n o tr e s p o n s i v et o e x t e r n a lr e s u s c i t a t i v em e a s u r e s ,i e ,h y d r a -
t i o na n d o x y g e np o s i t i o nc h a n g e s . T h e p a t i e n tw a st a k e nt o t h eo p e r a t i n gr o o mf o ra c ae s a r e ans e c t i o na n dd e l i v e r e da b o y ,w e i g h i n g9 6 4 g r a m s ,w i t h a n A p g a ro ft h r e ea t 1 m i n u t ea n d s e v e na t 5 m i n u t e s .T h ep l a c e n t aw a s 3 5 a b r u p t e d .T h e p a t i e n tw a s p l a c e d o n m a g n e -s i u m s u l f a t et h e r a p ya n d r e q u i r e d h y d r a l a z i n ea n ds o d i u mn i t r o p r u s s i d ef o rb l o o dp r e s s u r ec o n t r o l .
C a s e3A 2 9 - y e a r - o l db l a c kw o m a n p r e s e n t e da t 3 2 . 8w e e k s
g e s t a t i o n ,c o m p l a i n i n go fp r o f u s ev a g i n a lb l e e d i n ga n da b d o m i n a lp a i n .T h ep a t i e n ta d m i t st o s m o k i n gc o c a i n ea p p r o x i m a t e l y2 1 / 2p r i o rt o o n s e t o fp a i n .T h e p a t i e n ta r r i v e do n t h el a b o ra n d d e l i v e r ys u i t ea n d f e t a lh e a r tt o n e s w e r e 8 0 b e a t s / m i n u t e .T h e u t e r u sw a s t e n s et op a l p a t i o nw i t h o u tr e l a x a t i o n .T h e p a t i e n tw a s t ak e nt ot h eo p e r a t i n gr o o mf o ra n e m e r g e n c yc a e s a r e a ns e c t i o n .U p o no p e n i n gt h eu t e r u s ,7 0 0c c o fb r i g h tr e db l o o da n dc l o t sw e r e o b t a i n e d .T h e p a t i e n td e l i v e r e da g i r l ,w e i g h i n g1 8 1 4g r a m s .A p g a ra t 1 m i n u t ew a s f o u r ,a n da t 5 m i n u t e s ,s e v e n .T h e p l a c e n t aw a s 9 0 a b r u p t e d .T h e p a t i e n tw a s p l a c e do n m a g n e s i u ms u l f a t et h e r a p ya n d r e q u i r e dh y d r a l a z i n ea n d m e t h y l d o p af o r b l o o dp r e s s u r ec o n t r o l .
DISCUSSIONM a n i f e s t a t i o n so f c o c a i n e i n t o x i c a t i o na r e d e t e r -
m i n e db y t h ea m o u n to f d r u g i n g e s t e d ,m e t a b o l i s mo fd r u g p e r i n d i v i d u a l ,a n d i n d i v i d u a lt o l e r a n c e .
T h e s e r u mh a l f - l i f eo f c o c a i n ei s a p p r o x i m a t e l y1h o u r ,b u tc a n p e r s i s ti n t h ep l a s m af o r4 t o 6 h o u r s . 3C o c a i n e i s m e t a b o l i z e dp r e d o m i n a t e l yt o i n a c t i v ee c g o n i n e m e t h y l e s t e r b y p l a s m a a n d h e p a t i cc h o l i n e s t e r a s e s .P l a s m ac h o l i n e s t e r a s ea c t i v i t yi s d e -c r e a s e di n p r e g n a n c y,i n t h ef e t u s ,a n d i n p a t i e n t sw i t h
JOURNALOF TH E N AT I O N A LMEDICAL A S S O C I AT I O N ,V O L .8 3 ,N O .3 2 3 1
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