Hyperthermia. Malignant hyperthermia may occur with cocaine abuse. Mild exposures during the preimplantation period and more severe exposures during embryonic and fetal development often result in prenatal death and abortion. The fetus may be at risk for multiple anomalies.⁹ Treat this aggressively using same interventions as with nonpregnant patients.

Seizures. Patients having seizures or with a decreased level of consciousness generally need to be evaluated by noncontrast head CT scan. Assume that seizures are due to eclampsia after

20 weeks of pregnancy,¹⁰ even if BP is not elevated. Magnesium sulfate is the drug of choice. Benzodiazepines, fosphenytoin, levetiracetam, and propofol can be used for acute seizures, as in nonpregnant patients.^11-13

Mental changes. Combative patients may require sedation. Risk-benefit considerations often favor benzodiazepines for acute management. Some authorities suggest drugs with the longest established safety records, such as diazepam.¹⁴ Haloperidol does not appear to pose any teratogenic risk.¹⁵

Phenothiazines may lead to other complications and are used cautiously.

Designer Drugs

A variety of drugs ranging from K2 (also called spice) to mephedrone (often called bath salts) and MDMA derivatives are available on the Internet and their use is increasing. They are very difficult to identify in the analytical laboratory and produce a range of symptoms from hallucinations to agitation and hypertension. Some substances, such as “bromo-dragonfly,” may induce intense vasospasm. The general approach described for cocaine and amphetamines – starting treatment with benzodiazepines and controlling hypertension and hyperthermia – should be considered.

Opiates

Withdrawal, overdose, and complications are among the main issues in dealing with opioid abuse in pregnancy.

An intrauterine abstinence syndrome (IAS) is a potentially fatal consequence of maternal opiate withdrawal and is associated with developmental problems.¹⁶ Naloxone is safe otherwise,¹⁷ and to prevent maternal mortality or morbidity can be used as in nonpregnancy. Use should be avoided in the opiate-toxic patient who is relatively stable.

Newborn withdrawal from heroin or methadone can lead to sudden death. Heroin withdrawal typically presents within the first 24 hours, while methadone-exposed infants may not show symptoms of withdrawal until 72 hours after birth. Naloxone should be given to the newborn with significant opioid depression.

Alcohol

As in nonpregnancy, thiamine appears to be a safe and reasonable treatment for a suspected alcohol abuser. The issue regarding multivitamin/mineral infusions is more controversial.¹⁸ EPs can approach the pregnant patient as they do their other alcoholic patients.

Other Drugs

Generally, pregnant abusers of other recreational and prescription drugs are managed using the principles already discussed, with the primary issue often being legal and ethical considerations.

Ethical-Legal Issues

Pregnancy complications of drug use, aside from direct toxic effects, result from the lifestyle of the abuser (e.g., smoking, alcohol malnutrition, prostitution). Prenatal care is more likely to be inadequate.¹⁹ Of major concern to the EP in this setting are the ethical and legal responsibilities once drug abuse in pregnancy is identified. This often poses a real dilemma for the EP. Involving social services consultation early on may be helpful.