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At a glance

Polymalformative Teratogenic Syndrome characterized by growth disturbances, abnormalities of the fingers and toes, gastrointestinal and/or genitourinary tract, irritability, and arrhythmia with a danger of heart attack or stroke.

Synonym

Cocaine Antenatal Infection.

Nature

This “syndrome” has been challenged because even though cocaine is a known teratogen, there is no specific set of malformations associated with it, unlike the Fetal Alcohol Syndrome.

Incidence

Cocaine is used by approximately 1% of pregnant women in the United States.

Genetic inheritance

The condition is not genetic; rather it is a toxic syndrome therefore acquired.

Pathophysiology

The main effects of cocaine are mediated via dopamine and norepinephrine, the former being responsible for the euphoria and the latter for the harmful effects. Cocaine inhibits norepinephrine reuptake; thus it accumulates at the synaptic level and causes sympathetic activation, which translates to tachycardia, vasoconstriction, hypertension, and arrhythmias. During pregnancy, cocaine use can lead to decreased uteroplacental blood flow, vasoconstriction of the uterine vasculature, and subsequently hypoperfusion of the placenta. Finally, it also crosses the placenta and affects the fetus directly.

Diagnosis

In most of the studies, cocaine use was obtained through history or positive urine testing from the mother. However, if cocaine is not used for a few days (approximately 3 days), no metabolites will be detected in the urine.

Clinical aspects

Initially more preterm labor, precipitous labor, abruptio placentae, and small-for-gestational-age babies in women taking cocaine were reported, but some studies concluded that these occurrences were not related to cocaine use per se but to the absence of adequate prenatal care. Many malformations and behavioral effects caused by cocaine have been reported in the fetus, but with no specific pattern. Consequently, it is thought that the abnormalities are related to the timing and amount of drug used during the pregnancy and to the fact that abusers often use more than one type of drug. Some of the anomalies reported are skull malformations, cerebral infarcts, congenital cardiac defects (atrial septal defect, ventriculoseptal defect, valve stenosis, tetralogy of Fallot, Hypoplastic Left Heart Syndrome), neonatal arrhythmias and tachycardia, intestinal atresia, necrotizing enterocolitis, genitourinary malformations, limb defects, microcephaly, hypoplasia of the optic nerve, hypotonia, irritability, and seizures. Behavioral problems associated with attention deficit disorder are controversial. The association with an increased risk for Sudden Infant Death Syndrome has been suggested but not confirmed.

Precautions before anesthesia

Perform a complete physical examination to rule out the more obvious anomalies and then obtain an ECG, echocardiogram, and abdominal ultrasonogram based on the clinical findings.

Anesthetic considerations

The acute cardiovascular effects of cocaine on the fetus last for approximately 2 days, ...

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