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Abdominal aortic aneurysm in pregnant crack cocaine abuse patient. Shiraz E-Med J. In Dr Nicholls, physician to King George first described on necropsy an aortic dissection 1. Abdominal aortic aneurysm is a limited dilatation of the part of abdominal aorta just below the renal arteries and end above the iliac arteries. May be long up to 25 cm 2. The most common cause for degenerative process is atherosclerosis 3. Chief among risk factors is hypertension 3. Other causes include hereditary connective tissue disorders, aortic arthritis, chest trauma, bicuspid aortic valve 3. Possible other aortic disorders such as giant cell arthritis or systemic lupus also may predispose to dissection. AAA is very rare in young females. Crack cocaine users and pregnant woman are at increased risk of suffering from AAA 4. The cardiovascular complications related with cocaine abuse are adrenergic mediated, vasoconstriction, Include myocardial ischemia, infarction, myocarditis, thrombosis and aortic dissection 6. Cocaine decreases uterine blood flow and induces uterine contractions. It is clear, however, that women who use cocaine during pregnancy are at significant risk for shorter gestations, preterm labor, spontaneous abortions, PROM, abruption placenta, and death 7. Cocaine crosses the human placenta and is associated with free radical production, and fetal encephalopathy. Cocaine has teratogenic or adverse effects on developing brain 7. In this report we present the case of a crack user pregnant woman who develops an aortic aneurysm. The vasoconstriction and sympathomimetic effect of crack, coupled with cardiovascular changing during pregnancy, may predispose the patient to aortic aneurysm. A 32 year old woman who was 40 weeks pregnant with her second pregnancy came to the labor department complaining of labor pain and rupture of membrane. She had a previous cesarean section last year. She abused crack cocaine. She used crack every 2 hours. Physical examination revealed a temperature of An emergency cesarean section was performed; the neonatal was born with 1 minute and 5 minute Apgar score 7 and 9. The infant was transported to the neonatal intensive care unit. Testing for syphilis, hepatitis B surface antigen, human immunodeficiency HIV are non reactive. She was agitated and received 10 mg morphine and 10 mg diazepam in intensive unit. But she was restless and wanted more Illicit drugs. Suddenly blood pressure and pulse rate did not record by pulse oxymetry. The patient was pronounced dead 13 hours after cesarean section in intensive care unit. Her physicians suspected myocardial infarction, cerebral hemorrhage, amniotic fluid embolism or massive pulmonary embolism. Her neonatal suffered from post natal abstinence syndrome and morphine was used as the analgesic and withdrawal drug in NICU. Abdominal aortic aneurysms represent a degenerative process in the media of the arterial wall, resulting in a slow and continuous dilatation of the lumen of the vessel 8 , 9. The aortic wall contains smooth muscle, elastin and collagen arranged in concentric layers in order to withstand arterial pressure 1 , 8 , 9. Elastin is the principal load —bearing element in the aorta. Elastin degeneration and fragmentation are observed in aneurysm wall of aorta Most patient with aortic dissection are predisposed to a weakened or torn aorta to several factors 1 , 3. The most common cause is atherosclerosis 1 , 3 , 8 , 9 , Other causes include hereditary connective tissue disorders, such as Marfan and Ehlers-Danlos syndromes, granulomatous vasculitis of the aorta, chest trauma caused by a motor-vehicle accident, Turner syndrome 1 - 3 , 8 , 9 , Another risk factor for aortic dissection is the use crack cocaine in pregnant woman 3 , The proposed mechanism of aortic dissection during cocaine abuse is mediated through catecholamine-induced, vasoconstriction, acute profound elevation of heart rate, BP and myocardial contractility causing a rapid rise in the derivative of pressure on the aortic wall resulting intima tear 14 , Cardiovascular changes during pregnancy are: increased stroke volume, blood volume, heart rate, cardiac output and increase in the left ventricular wall mass 2. The increased production of estrogens, prostacyclins, nitric oxide contributes to a decrease in peripheral vascular resistance in aortic compliance 2. Nitric oxide is involved in the progression of AAA Rupture of the aorta in pregnancy usually occurs when blood volume and cardiac output are rising to a maximum. It has been known to occur at all stages of pregnancy and during the weeks after delivery. Cocaine use and activities that cause sudden rise in blood pressure such as weight lifting have been implicated 4. High blood pressure generated during weight changing, an increased ventricular ejection forces, accompanied by the Valsalva maneuver may be the cause of aortic dissection 5 , 9. Most people with AAA have no symptoms unless the aneurysm ruptures. Occasionally AAA can produce abdominal or back pain, or a tender spot in the abdomen 1 , 3 , 8 , 9 , Rupture of an AAA usually causes massive internal bleeding and is often quickly fatal 17 , Patients may have normal vital signs in the presence of ruptured AAA due to retroperitoneal containment of hematoma. Presence of a pulsatile abdominal mass is virtually diagnostic but is found in less than half of cases. The diagnosis may be confused with renal calculus, diverticulitis, incarcerated hernia, or lumbar spine disease 1 , 3 , 8 , 9 , 12 , AAA also are less common in women than in men, and , as with coronary heart disease, there is evidence that women with AAA also have a worse prognosis. AAA in pregnancy is uncommon and occurs in the late stage of pregnancy. Complication related to cocaine abuse includes myocardial ischemia, thrombosis, aortic dissection, sudden cardiac death. Crack cocaine smoking cessation, healthy lifestyle, preconception counseling and prenatal care are associated with lower risk of maternal mortality 2 , 22 , Acute aortic syndromes. Obstetricia de Williams. McGraw Hill Brasil; Nicholas B. Aortic Dissection receives new attention following sudden death of Actor John Ritter. Clinical Lab products. Robinson R. Aortic aneurysm in pregnancy: a case study. Dimensions of Critical Care Nursing. Aortic dissection during pregnancy. British heart journal. Cardiovascular complications of cocaine: Imaging findings. Emergency radiology. Weiner CP, Buhimschi C. Drugs for pregnant and lactating women. Elsevier Health Sciences; Journal of the American College of Cardiology. Clinical, diagnostic, and management perspectives of aortic dissection. Chest Journal. Collagen degradation in the abdominal aneurysm: a conspiracy of matrix metalloproteinase and cysteine collagenases. The American journal of pathology. Abdominal aortic aneurysm the prognosis in women is worse than in men. Braverman AC. Acute Aortic Dissection Clinician Update. Acute aortic dissection related to crack cocaine. Acute aortic dissection—vascular emergency with numerous pitfalls. Emergency abdominal aortic aneurysm presenting without haemodynamic shock is associated with misdiagnosis and delay in appropriate clinical management. Emergency Medicine Journal. Glauser J. Aortic Dissection: The Great Imitator. Emergency Medicine News. Clinical features and diagnosis of abdominal aortic aneurysm. International Journal of Drug Policy. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. Journal of vascular surgery. We use cookies to provide you with the best possible experience. They also allow us to analyze user behavior in order to constantly improve the website for you. Navigate to Shiraz E-Medical Journal. Abdominal aortic aneurysm in pregnant crack cocaine abuse patient authors:. Shiraz E-Medical Journal: Vol. Abstract Back ground: Rupture is a fatal complication of abdominal aortic aneurysm. An aneurysm is defined as ruptured when bleeding is present outside of the wall of the aneurysm. Case presentation: A 32 year old woman crack user, in 40 weeks pregnancy came to labor department. An emergency cesarean section was performed. She expired 13 hours after surgery. Autopsy detects dissection of abdominal aortic aneurysm. Conclusion: Sympathetic agonist and vasoconstriction effect of crack resulting increased blood pressure, heart rate, myocardial contractility would increase the risk of aortic dissection. Introduction In Dr Nicholls, physician to King George first described on necropsy an aortic dissection 1. Case study A 32 year old woman who was 40 weeks pregnant with her second pregnancy came to the labor department complaining of labor pain and rupture of membrane. She did not receive adequate prenatal care in this pregnancy. The patient was pronounced dead 13 hours after cesarean section in intensive care unit Her physicians suspected myocardial infarction, cerebral hemorrhage, amniotic fluid embolism or massive pulmonary embolism. Discussion Abdominal aortic aneurysms represent a degenerative process in the media of the arterial wall, resulting in a slow and continuous dilatation of the lumen of the vessel 8 , 9. Conclusions AAA also are less common in women than in men, and , as with coronary heart disease, there is evidence that women with AAA also have a worse prognosis. References 1. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4. Leave a comment here:. Cookie Setting We use cookies to provide you with the best possible experience.

Abdominal aortic aneurysm in pregnant crack cocaine abuse patient

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Official websites use. Share sensitive information only on official, secure websites. Address correspondence to Dr. We examined the ability of several baseline variables to predict treatment outcome in a pharmacotherapy trial that included participants who were both cocaine- and alcohol-dependent and were selected for a randomized, double-blind, placebo-controlled study. Predictor variables included results from the baseline Addiction Severity Index ASI , initial Urine Drug Screen results, cocaine and alcohol craving and cocaine and alcohol withdrawal symptoms at the start of treatment. Successful treatment was defined as four continuous weeks of self-reported cocaine abstinence verified by urine drug screens. In respect to demographic characteristics, there were no significant differences between patients who achieved four weeks of abstinence from cocaine and those who did not. Baseline variables that most consistently predicted cocaine abstinence included initial urine drug screen UDS results, the initial Cocaine Selective Severity Assessment CSSA scores, and initial self-reported cocaine use in past 30 days, whereas cocaine craving, cocaine composite scores, alcohol craving, alcohol withdrawal symptoms, and alcohol composite scores did not. The results of this study suggest that cocaine dependence severity in general, and initial UDS results, the CSSA scores and frequency of recent cocaine use in particular, have a significant impact on treatment outcome in the treatment of cocaine-dependent patients with comorbid alcoholism. Initial UDS results and CSSA scores are very useful predictors of treatment outcome and could be used as stratifying variables in outpatient cocaine and alcohol medication trials. Our intention in this paper is to find predictors of treatment outcome in the outpatient treatment of cocaine-dependent patients with comorbid alcoholism. This could be useful for the development of both pharmacological as well as psychosocial treatments for cocaine dependence and dual alcohol and cocaine dependence. Among the strongest predictors of response to treatment in cocaine-dependent patients are cocaine withdrawal symptom severity and the results of a urine drug screen collected at the treatment entry. Concurrent dependence on cocaine and alcohol is extremely common and very difficult to treat. Patients who are dually cocaine- and alcohol-dependent tend to have more psychosocial problems compared to patients addicted to alcohol alone 9 or compared to patients addicted to cocaine alone. High dropout rates are a major problem in the outpatient treatment of cocaine dependence 11 , 12 and cocaine—alcohol dependence. Other research studies have shown that patients with more severe cocaine withdrawal symptoms were less likely to complete initial abstinence from cocaine in comparison with patients who had less severe cocaine withdrawal symptoms. Although much is known about predictors of treatment outcome among cocaine-dependent patients, less is known about predictors of treatment outcome among cocaine-dependent patients with comorbid alcoholism. In this trial, we sought to examine predictors of treatment outcome in cocaine-dependent patients with comorbid alcoholism who were participating in an outpatient pharmacotherapy trial. We analyzed data from consecutive cocaine- and alcohol-dependent patients who gave written informed consent for a clinical study of naltrexone for the treatment of coaine and alcohol dependence. We compared demographics, pretreatment drug and alcohol use data, cocaine and alcohol withdrawal symptoms, and cocaine and alcohol craving symptoms of participants who successfully achieved four weeks of cocaine abstinence to participants who failed to achieve four weeks of cocaine abstinence. Of patients who signed consent and began screening, patients completed detoxification and entered a week trial. The participants were men and women between the ages of 18 and 65 who were seeking treatment for both cocaine and alcohol dependence and were consecutive admissions to an outpatient treatment research study for cocaine-dependent patients with comorbid alcoholism at the University of Penn-sylvania. Participants were recruited through advertisements in the local media, and those who met criteria in an intake appointment were referred to treatment in a randomized double blind placebo-controlled naltrexone trial for the treatment of cocaine and alcohol dependence. Participants were paid for participation and received a comprehensive psychiatric and medical evaluation prior to entry into the study, and were both cocaine- and alcohol-dependent at the time of study entry. Informed consent was taken from all participants. All measures were completed before the participant received any medication or therapy. Participants who successfully completed detoxification from alcohol and cocaine then entered a week double-blind, placebo-controlled trial comparing naltrexone mg daily to placebo. The primary outcome measures included urine drug screens obtained twice weekly and alcohol use measured by self-report using a timeline followback. Predictor variables were obtained at treatment entry. Baseline demographics, drug and alcohol use, and drug and alcohol dependence severity were obtained using the Addiction Severity Index ASI at the first detoxification visit and prior to treatment. Cocaine craving was measured using a mm visual analog scale VAS , which was included as part of the Minnesota Cocaine Craving Scale at the first detoxification visit and prior to treatment. For alcohol craving, the visual analog scale described above was modified for alcohol. Participants were asked to rate their strength of their craving for alcohol, on average, over the past week, and prior to treatment. Alcohol withdrawal signs and symptoms were assessed at the first visit and prior to treatment using a modified version of the Selective Severity Assessment SSA-M. The SSA-M was specifically designed to assist with the outpatient detoxification of alcoholics. The CSSA is an item, interviewer-administered measure of the severity of cocaine abstinence symptoms. A total CSSA score is derived by a summation of the individual item scores. The CSSA measures signs and symptoms that commonly occur after abrupt cessation of cocaine use as reported in the literature and observed by clinicians at the University of Pennsylvania Center for the Treatment of Addictions. Signs and symptoms measured include cocaine craving, depressed mood, appetite changes, sleep disturbances, lethargy, and bradycardia. In recent reliability and validity testing, the instrument was found to be a valid and reliable measure of symptoms associated with the abrupt cessation of cocaine use. In the original work, 3 the CSSA was found to have excellent interrater reliability and internal consistency. It was found to be specific to cocaine-dependent patients and decreased as patients maintained abstinence over eight days. Initial CSSA scores predicted poor outcome in treatment. The initial CSSA score was obtained on the first day of detoxification. This trial evaluated the ability of the selected baseline variables to predict a successful treatment outcome for cocaine use, defined as four weeks of continuous abstinence from cocaine, verified by urine drug screens.. In previous cocaine pharmacotherapy trials, a stable period of continuous abstinence from cocaine 3—4 weeks was found to be predictive of long-term cocaine abstinence. Data analyses were performed with statistical software SPSS version Demographics and pre-treatment drug use were compared between patients who achieved four weeks of continuous abstinence from cocaine and those who did not. When necessary, the data were transformed to reduce skew prior to analysis. Predictor variables were first compared individually. Cocaine craving and alcohol craving as measured on the VAS on the first day of detoxification were compared between treatment completers and treatment failures. Cocaine and alcohol withdrawal severity measured by scores on the CSSA and SSA-M on the first day of detoxification was likewise compared between treatment completers and treatment failures. Finally, logistic regression was used to identify the strongest predictors of treatment success. The dependent measure was cocaine abstinence for four continuous weeks. Individual predictor variables were drawn from demographic variables see Table 1 , baseline cocaine use variables see Table 2 , and baseline alcohol use variables see Table 2. These were first entered into a logistic regression equation individually. A forward stepwise technique was used in which variables were entered in order of significance. This technique was used in this exploratory analysis because we had no preset theory regarding which variables should be included in the final model. The forward stepwise technique allows for the evaluation of the predictive power of each variable as other variables are entered into the equation. The mean age was With respect to demographic characteristics, there was no significant difference between treatment completers and treatment failures. According to Table 1 , baseline measures of alcohol dependence differed little between those who attained sustained abstinence from cocaine cocaine abstainers and those who did not cocaine nonabstainers. Out of the eleven baseline alcohol use variables tested, only one variable, alcohol treatments per lifetime, was significantly different. The severity of alcohol withdrawal symptoms and the severity of alcohol craving were not significantly different between the two groups. Baseline measures of cocaine dependence severity varied in a number of variables between cocaine abstainers and nonabstainers. Out of the eleven baseline cocaine use variables examined, four differed significantly between the two groups of patients. To find which variables best predict sustained abstinence from cocaine, we entered each individual demographic and drug and alcohol use variable see Table 1 into a separate logistic regression equation. All variables that were significant predictors of cocaine abstinence are shown in Table 2. These predictor variables were then entered into a single logistic regression equation in a forward stepwise manner. Among cocaine-dependent patients with comorbid alcoholism, it was the severity of cocaine dependence, specifically the initial urine drug screen, the self-report of cocaine use, the severity of cocaine withdrawal symptoms, and the frequency of recent cocaine use that best predicted sustained abstinence from cocaine. Patients who attained sustained abstinence form cocaine differed from patients who did not achieve abstinence in only one of alcohol use variables, compared to four cocaine use variables. In cocaine use variables that were significantly different, cocaine nonabstainers had signs of more severe cocaine dependence. Furthermore, when each demographic and drug use variable was entered individually into a regression equation to predict sustained abstinence from cocaine, none of alcohol use variables proved to be a significant predictor. On the other hand, three of cocaine use variables proved to be significant predictors of sustained cocaine abstinence: the urine drug screen, the severity of cocaine withdrawal symptoms, and the frequency of recent cocaine use. Thus, the results of this study reinforce and extend the previous findings, that cocaine dependence severity adversely affects treatment outcome. This trial included outpatient participants who were dependent on both cocaine and alcohol, and most participants reported mild to moderate alcohol withdrawal symptoms. Participants who experienced more intense alcohol severity were referred to an inpatient center. Therefore, care must be taken not to generalize these findings to all cocaine- and alcohol-dependent patient populations. The results of the current clinical trial suggest that cocaine dependence severity in general, and initial urine drug screen results, CSSA scores, and frequency of recent cocaine use in particular, have a significant impact on treatment outcome in the treatment of cocaine-dependent patients with comorbid alcoholism. Initial urine drug screen results and CSSA scores are very useful predictors of treatment outcome and should be used as stratifying variables in outpatient cocaine and alcohol medication trials. This work was supported by grants P50 DA Dr. Pettinati and P60 DA Dr. As a library, NLM provides access to scientific literature. Am J Addict. Published in final edited form as: Am J Addict. Find articles by Jamshid Ahmadi. Find articles by Kyle M Kampman. Find articles by David M Oslin. Find articles by Helen M Pettinati. Find articles by Charles Dackis. Find articles by Thorne Sparkman. The publisher's version of this article is available at Am J Addict. Alcohol and cocaine use variables, expressed as means standard deviation. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Days of alcohol use to intoxication in past 30 days. Negative self-reported cocaine use, verified by cocaine-negative urine.

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