Because of significant implications in pregnancy, consider testing IV drug users for HIV and hepatitis B using the legal principles described below.

With cocaine, if abruptio placentae is in the differential (uterine pain, tenderness, vaginal bleeding may or not be present), order a CBC, type and cross for packed RBCs, DIC profile, and ultrasound. Monitor for uterine contractions and fetal heart rate.

Cocaine and Amphetamines

Clinical Presentation

Cocaine or amphetamine (e.g., meth­amphetamine) intoxication may mimic preeclampsia/eclampsia, with elevated blood pressure, muscle twitching, and hyperreflexia.^4,5 This may progress to grand mal seizures or status epilepticus. After 20 weeks, consider the possible coexistence of intoxication and preeclampsia/eclampsia.

Spontaneous coronary artery dissection is a rare entity leading to acute coronary syndrome and sudden cardiac death, and therapeutic management options are variable. The literature describes a young patient who presented with ST-elevation myocardial infarction (STEMI) due to coronary artery dissection secondary to cocaine abuse.⁶

Cocaine is associated with increased risk of placental abruption. Uterine pain, with or without bleeding, should warrant an OB consult. Order a CBC, type and cross for packed RBCs, DIC profile, and ultrasound (which lacks significant sensitivity). Have L&D staff monitor for uterine contractions and fetal heart rate.

Symptom-Specific Treatment

Hypertension, tachycardia. As in nonpregnant patients, hypertension and tachycardia may often respond to benzodiazepine sedation. Be aware that if delivery is imminent, the neonate may have significant sedation from benzodiazepines, so notify the delivery team if they are used.⁷

For pregnancy beyond 24 weeks, consider that the supine patient may have falsely decreased BP from vena caval compression. Check BP in the left lateral decubitus position to verify numbers. Nitroglycerin can also be used to control hypertension and treat chest pain if needed. This is a reasonable next step after benzodiazepines. After 20 weeks, consider magnesium sulfate to cover preeclampsia/eclampsia.

Nitroprusside is relatively contraindicated secondary to potential fetal cyanide poisoning.

Labetalol, commonly used for hypertension in pregnancy, poses a risk if the patient is cocaine toxic due to more beta- than alpha-adrenergic antagonist effects. The beta-blocking effects should be avoided in this setting.

The role of calcium channel blockers in the treatment of patients with cocaine-associated ACS remains uncertain. Calcium channel blockers should not be used as a first-line treatment but may be considered for patients who do not respond to benzodiazepines and nitroglycerin. Nicardipine is the shortest-acting of the calcium channel blockers.

Phentolamine is an alpha-adrenergic antagonist that may affect vasoconstriction, can be used for severe hypertension, and is considered a second-line agent for chest pain. It appears to increase uterine blood flow.⁸