Cocaine and fetal death

181

Forensic Science International, 47 (19901 181- 189 Elsevier Scientific Publishers Ireland Ltd.

COCAINE

AND

FETAL

DEATH

I. MORILD’ and M. STAJIQ uDepartment bDepartment (Received (Accepted

of Forensic Medicine, The Gade Institute, University of Toxicology, Office of Chief Medical Examiner, New

of Bergen INorway) and York, NY 1U.S.A.I

April lOth, 19901 May 3rd. 19901

Summary Toxicologic screening for cocaine and its metabolites was performed on 103 cases of fetal death autopsied in the Office of Chief Medical Examiner, City of New York. In 64 cases cocaine or its metabolites were found in the blood or in the brain. Some malformations were also found. The study indicates that maternal use of cocaine may lead to abruptio placentae, abortion and fetal death. The importance of toxicologic examination in these deaths is emphasized. Key words: Cocaine; Fetal death; Malformations;

Abruptio

placentae

Introduction Recreational abuse of cocaine has been increasing in the United States and in other parts of the world since it became less expensive and more readily available [l]. Cocaine is an alkaloid agent prepared from the leaves of the plant Erythroxylon coca. It is most frequently used in the form of a powder, which is readily absorbed from all mucous membranes. “Snorting”, or the intranasal route is the most popular way to take cocaine today. Many users also administer the drug intravenously. Lately there has been an almost epidemic increase in the use of “crack”. This substance is the free base of cocaine. After removal of the hydrochloride portion the free base can be smoked. During the last decade there has been a dramatic rise in the use of cocaine by pregnant women [2], and several reports have suggested that cocaine use during pregnancy may influence the outcome of the pregnancy [3,4]. The use of cocaine has been associated with lower gestational age at delivery, an increase in preterm labor and delivery, lower birth weights and delivery of infants small for gestational age [5]. Some reports [3,4] have linked cocaine use to abruptio placentae and fetal death. Maternal cocaine use has also been shown to be associated with congenital malformations [6]. Recently forensic pathologists have been encouraged to report information of cocaine abuse in their jurisdiction [7]. 0379-0738/90/$03.50 0 1990 Elsevier Scientific Publishers Printed and Published in Ireland

Ireland Ltd.

182

The crack epidemic in New York is a problem of enormous dimensions. In 1980 the rate of maternal drug use was 7.4 per 1000 live births. By 1988, this rate had risen to 29.7 [2]. Child welfare experts believe that crack is responsible for the recent rapid increase of child abuse and neglect in New York City. One way to obtain information about this group of women is to examine all fetal deaths in order to reveal the presence of cocaine. Many users tend to understate their drug use [8]. In cases of fetal deaths, a toxicologic examination of the dead fetus therefore should be part of the autopsy routine both to clarify the cause of death and to demonstrate maternal abuse of cocaine. Materials and Methods Toxicologic examination was performed on all cases of fetal death reported to the Office of Chief Medical Examiner (OCME), from March 1987 to April 1989. The OCME investigates all deaths in the City of New York occurring “from criminal violence, by a casualty, by suicide, suddenly when in apparent health, when unattended by a physician, in (prison) facilities of the Departments of Correction and Juvenile Justice or in any unusual or suspicious manner”. All samples for toxicologic analyses were screened by radioimmunoassay (RIA) (Abuscreen Hoffmann La Roche Inc., Nutley, NJ) to detect cocaine, benzoylecgonine and related substances. Whenever possible, blood was taken from the fetuses for analysis. In most cases brain tissue was also analysed. In some cases, neither blood nor brain substance could be analysed due to maceration and advanced autolysis. Results A total of 103 fetal deaths were examined in the period. Sixty-four cases had cocaine either in the blood or in the brain. In 51 available blood samples cocainelbenzoylecgonine was found in 50 (Fig. 11. In 60 brains cocainelbenzoylecgonine was found in all but one (Fig. 21. In 47 cases both blood and brain were available for analysis. One case had cocaine in the blood, but not in the brain. The highest blood concentration found was 4.8 mg/l, while the mean concentration was 0.8 mg/l. Three cases had cocaine in the brain, but not in the blood. The highest concentration found in the brain was 3.6 mg/kg and the mean concentration was 1.1 mg/kg (Figs. 1 and 21. Body weight of the fetuses are given in Fig. 3. There was a range from 160 to 3780 g. The mean weight was 1480 g. Crown-heel measurement showed a mean length of 38 cm and a range from 20 to 53 cm (Fig. 4). In most cases the gestational age could be estimated, ranging from 17 to 42 weeks with a mean age of 29 weeks (Fig. 51. Information of the prenatal care was usually very scanty. Many had not

183

Bloodconc.

cocain/benzoylecgonine Fetal

death

8

a

0.5

1.0

Fig. 1. Blood concentration available blood samples.

1.5

2.5

3.0

3.5

Concentration

-

wz/L

of cocaine

2.0

and/or

its major

metabolite

4.0

benzoylecgonine

4.5

5.0

in 50 of 51

seen a doctor during their pregnancy and many had had no prenatal care at all. Several mothers had left the hospital immediately after delivery and in some cases the mother could not be traced. Most deliveries took place at home and very little information of the delivery was available (Table 11. Only nine babies were born alive, 55 were stillborn (Table 21. Most fetuses were black, followed in number by Hispanics and white (Table 21. There were 35 males and 29 females (Table 21. In many cases the mother told that the labor started only minutes after inhalation of crack. Some mothers told about abdominal cramps after crack use and of cessation of fetal movements from that moment. In 35 of the cases there was information of maternal cocaine abuse during the pregnancy, while abuse was denied in six cases. No information was available in 23 cases (Table 11. The autopsy revealed relatively few pathologic findings. One fetus had a congenital malformation of the heart (Tetralogy of Fallot). One had a severe malformation of an upper extremity, and one had a hypoplastic right lung. Due to delivery on a kitchen floor one suffered a head injury, and one had a small spontaneous intracerebral hemorrhage. Several of the alive born

184

Brainconc.

cocaine/benzoylecgonine Fetal

0

0.5

1.0

1.5

death

2.0

Concentration Fig. 2. Brain concentration of cocaine available brain tissue samples.

and/or

its major

2.5

-

3.0

3.5

4.0

mg/Kg

metabolite

benzoylecgonine

in 59 of 60

babies suffered from severe respiratory distress syndrome (RDS). They died shortly after birth, and hyaline membranes were found in the lungs. Discussion Cocaine is rapidly metabolized in the body and probably also postmortem [9]. The concentration of cocaine found at the autopsy may therefore not be representative for the concentration at ihe time of death. The concentration of the metabolite, benzoylecgonine, accumulates with time due its longer half life [lo]. In the present study the sum of the amount of cocaine and its metabolites was calculated in both blood and brain as recommended by others [ll]. There is probably no blood-brain barrier for cocaine. Even an active transport of cocaine into the brain has been suggested [12]. Benzoylecgonine does not pass the blood-brain barrier as easily as cocaine [13- 151. In a report of cocaine overdoses, the brain concentration of cocaine was about four times the blood concentration [lo]. Most studies have, however, been performed on adults where the metabolism of cocaine is relatively well

185

Body Fetal

m

400

800

1200

weight death

Number

1600

2000

of cases c

2400

Body weight -

2800

3200

3600

grams

Fig. 3. Body weight of the 64 fetuses as measured at autopsy. The mean weight was 1480 g.

known. The metabolism of cocaine in the fetus cannot be compared directly to the metabolism in adults. In the fetus the metabolism has been shown to be very slow, probably related to the immaturity or the relative deficiency of plasma cholinesterases [16]. It is known that cocaine reduces uterine blood flow, which in turn may lead to fetal hypoxia, dangerous to the vulnerable fetus. The direct toxic effect of cocaine on the fetus is not very well known. However, studies have shown that the fetal blood concentration of cocaine observed 5 min after maternal infusion were approximately 12% of the corresponding maternal levels [17]. These studies were performed on fetuses of pregnant ewe. In a recent report concerning cocaine in a pregnant woman, the fetus had a blood concentration of 1.5 mg/l cocaine while the mother had 13.7 mg/l [18]. This high maternal/fetal ratio might be the result of cocaine induced vasoconstriction reducing blood flow to the pregnant uterus [18]. However, the high ratio may also be the result of fetal blood not reaching equilibrium with the maternal blood concentration before death. Brain and blood concentrations in acute overdoses are usually higher than the concentrations in the present

186

Crown-heel Fetal

length death

li, 0

lc

I 25

30

35

Crown-heel

40

length

45

-

50

--J 55

cm

Fig. 4. Crown-heel length of the fetuses as measured at autopsy. The mean length was 38 cm.

study where the blood and brain concentrations were moderate. The present findings still indicate that the maternal intoxication must have been significant in most cases. However, an accumulation in the fetus caused by chronic maternal use may also be an explanation. In a study of cocaine positive fatalities, overdose was responsible for only 4010 of the deaths [19]. However, in cases where death was attributed to cocaine intoxication, manifested by circulatory and respiratory failure, the concentrations of cocaine were comparable to the concentrations in the present study. Cocaine is known to be a very potent vasoconstrictive agent. In studies on the pregnant ewe, the cardiovascular effects of cocaine on the fetus were significant with a rise in blood pressure, but without change in the pulse rate [17]. Several reports have linked cocaine use during pregnancy to abruptio placentae and fetal death [3-551. In some cases of the present study information of the delivery was highly suggestive of abruptio placentae caused by cocaine use, but no conclusion could be drawn. Another problem was that no placentas were available for examination. Placental examination should be a routine procedure in any examination of fetal death.

187

Gestational Fetal

age

death

1716192021222324252627262930313233343536373639404142

Gestational Fig. 5. Gestational

age -

weeks

age of the fetuses as estimated at autopsy. The mean age was 29 weeks.

Few pathologic findings were made in the study. One was a severe deformity of an upper extremity. Limb reduction defects have been connected with fetal vascular compromise [20]. The finding of a Tetralogy of Fallot may be incidental, but we feel that it is important to report it. Larger studies are necessary to examine the possible role of cocaine as the causative agent. The

TABLE

I

EPIDEMIOLOGIC

DATA

ON THE MOTHERS No.

Delivery Home Hospital Other

45 16 3

Drug abuse history Positive Negative No information

35 6 23

188 TABLE

II

EPIDEMIOLOGIC

DATA

ON THE FETUSES No.

Race Black Hispanic White

46 15 3

Sex Male Female Fetuses at birth Liveborn Stillborn

35 29

9 55

intracerebral hemorrhage in one case was spontaneous and probably related to the prematurity which again may have been caused by cocaine use. The low birth weight, length and gestational age reflects the prematurity of most fetuses. Hydronephrosis was suspected clinically in one case diagnosed by ultrasound. However, this could not be found at autopsy. Urogenital anomalies have been shown to be associated with cocaine abuse [6]. The majority of the fetuses were black and most were born outside hospital. This has been usual in similar studies [2]. Most fetuses were stillborn, but some lived a few hours with severe respiratory distress which is common with severe prematurity. It seems evident from several of the cases in this study that cocaine was the agent leading to premature delivery, and thus attributing to fetal death. Congenital anomalies may be associated with cocaine abuse. It is therefore necessary to report anomalies in cases where there has been abuse of cocaine. The examination of fetal deaths should include a toxicologic screening. It is possible to detect cocaine and/or its metabolites in the dead fetus, even after weeks. The finding of cocaine or its metabolites in the fetal body indicates maternal use. References C.V. Wetli and R.K. Wright, Death caused by recreational 2519 - 2522.

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