Eclampsia in HIV Cocaine Abuser at 25 weeks old gestational age
A 43 year old African American female presented to our facility with high-grade fever, seizures, elevated blood pressure and altered mental status. Our laboratory investigations revealed HIV positive serum, elevated alanine transaminase (ALT) and aspartate transaminase (AST) enzymes, proteinuria, Urinary Tract infection, leucocytoses, a urine toxicology screen that was positive for cocaine and a positive pregnancy test. A fetal sonogram showed a viable 25 week gestational age fetus and subsequently a diagnosis of Eclampsia in a newly diagnosed HIV was made.
Patient was stabilized on intravenous Magnesium Sulphate, labetalol drip, antibiotics and zidovodine (AZT) for 48hrs before undergoing a classical Cesarean section on day 3 of admission. In our case report we discuss the outcome of her pregnancy and the consequences it has socially and medically for the newly delivered child; we also elaborate on the challenges a physician faces in the management of this condition and how to for stall future occurrences
Key words: Eclampsia, HIV/AIDS, cocaine
A 43 year old African American female G7P6006 was brought to our facility s/p two witnessed generalized tonic clonic (GTC) seizures at home in altered mental status by emergency medical services (EMS). Her history at the time of presentation was unknown as patient was unregistered, uninsured and undocumented at the time of presentation. At the initial presentation our patient was stuporous, febrile (102.80F) with markedly elevated Blood Pressure (228/118mmHg). Patient was also tachycardic (103/min), tachypneic (34/min) with a prominent distended lower abdominal bulge which was non-tender, mobile but limited to the pelvic region. Her urine human chorionic gonadotropic (HCG) test was positive and a diagnosis of eclampsia in a multi parous pre-term patient was made.
Patient was immediately transferred to the surgical intensive care unit (SICU) and started on intravenous magnesium sulphate (for seizure control) and labetalol drip (for blood pressure control). This was after initial attempts at controlling the blood pressure with intravenous hydralazine proved unsuccessful. Laboratory findings included a positive HIV serological test with a viral load of 35200, CD4 count of 480, AST and ALT elevations of 249 units/ml and 95 units/ml respectively and an elevated white blood count (WBC) of 14,300/ml. Urine toxicology screen was positive for cocaine and patient was started on intravenous antibiotics consisting of ampicillin, gentamicin, metronidazole and aztreonam and intravenous zidovudine (AZT) drip; intravenous dexamethasone (to reduce maternal-fetal HIV transmission and augment fetal lung maturity respectively) was also administered for 48 hours.
Other tests carried out were a computed tomography (CT) scan of the Head (without contrast) which showed vasogenic edema but no evidence of hemorrhage or infarct. A decision was made to operate on day three of admission and patient underwent a classical cesarean section under general anesthesia (G.A) presentation with APGAR scores of 1, 3 and 7. The infant was intubated at birth and kept on a ventilator for two weeks for transient tachypnea in the Neonatal Intensive Care Unit (NICU). The infant was, immediately after birth, started on AZT and has remained negative for HIV till date. The placenta in our patient showed evidence, on pathologic review, of ischemia and infarction consistent with eclampsia.
In view of the circumstances leading up to the delivery, child protective services (CPS) were notified and the baby was discharged to foster care from the NICU. Our patient, however, was discharged on post-operative day five after social work evaluation, safe sex counseling and education on her condition. She is currently on 60mg Methadone once a day treatment for detoxification and is yet to start Highly Active Anti Retroviral Treatment (HAART) due to her non-compliance with follow-up arrangements.
Of the 1.75 million cocaine abusers in the United States in 19961 about 20-25% were positive for HIV2 making IVDA the second leading risk factor (2nd only to heterosexual contact) for contacting HIV in the western world. The prevalence of cocaine use during pregnancy was estimated in a 1992 study of indigent Atlanta-based mothers as 13.3%3 and is characteristic of older, single, black and multiparous women3. These demographics are at variance with those typically found in eclamptic patients who are typically nulliparous young women in their teenage years to low twenties from lower socioeconomic backgrounds4.
Our literature search found no documentation of cocaine users with HIV infection presenting in eclampsia. The closest we got was a study done at the National Institute of Allergy and infectious diseases5 comparing the outcomes of HIV positive children born to HIV positive maternal users of cocaine and non-HIV infected children born to HIV positive maternal users of cocaine by Rodriguez et al5. The results showed that irrespective of HIV status children were more likely to have shorter gestational ages (by one to two weeks), lower birth weights (by 233gm), shorter length (by 1.7cm) with smaller head circumference (by 0.7cm) if there was maternal use of cocaine during pregnancy5.
Cocaine, HIV and eclampsia cases are leading causes of morbidity and mortality individually and as a combination (like our patient had) are deathly. In Mexico, for example, eclampsia has a mortality rate of 14-22%6 compared to what is seen in prenatal care in western-world tertiary centers with a maternal mortality of 0 to 1.8%7. Our patient had no prenatal care and was not even aware she was pregnant when she presented at 25 weeks gestational age in eclampsia. She suffered from the complications of all three disease entities - Cocaine, HIV and eclampsia - including preterm labor, IUGR, neurobehavioral impairment, HTN, psychosis, seizures and sepsis.
It is well documented in studies by Ellerbrock et al8 that HIV-infected individuals who use cocaine have an increased number of sex partners ((> 4 partners per month), tend to use condoms less and engage in sex for money or drugs8. Other commentators have reported an increase in mother-to-child HIV transmission among maternal cocaine drug users with Rodriguez et al reporting a higher risk (26.9 versus 16.3%; P=0.003)9 of transmission among women who used cocaine during pregnancy relative to non-cocaine users. If our patients cocaine habit had been adequately tackled, by a concerted detoxification service, her errant sexual behavior that led (possibly) to her HIV infection, undocumented preterm pregnancy and (eventually) eclampsia may have been stemmed. It is a sad commentary on our social welfare system that this patient was a “drop-out” of two previous detoxification programs with no subsequent follow-up.
Following suggestions in some quarters that HIV may protect pregnant women from eclampsia a study comparing eclampsia incidence in HIV-positive and HIV-negative women was done in South Africa by Frank et al10. The results showed that HIV does not reduce the risk of developing eclampsia with no statistical difference between those with HIV who developed eclampsia (5.7%) and those that did not (5.2%)10. Even though our patients cause of eclampsia could be cocaine induced our clinical and laboratory findings including multiple seizures, elevated blood pressure, elevated liver enzymes and positive proteinuria indicate that our patient had an eclamptic episode that was probably exacerbated by cocaine use. It is also interesting to note that intravenous labetalol, a beta blocker, was used in our patient without any cardiovascular incident even though it is relatively contra-indicated in cocaine positive individuals.
An outcome of this case report is the need to highlight the need for urine toxicology screens on HIV positive pregnant women and individuals with high risk sexual behavior. Also, the need to concertedly and aggressively follow-up past drug users - especially those in the reproductive age group – cannot be over emphasized. The $8,766 to $11,925 per neonatal hospitalization cost (or $6.2 billion in total)4 spent on babies born to maternal cocaine users annually can be more efficiently used for surveillance, counseling and contraception provision to this socially neglected and medically irresponsible population.
- National Institute on Drug Abuse. Pregnancy and drug use trends. www.drugabuse.gov/infofacts/pregnancytrends.html (Accessed 2/10/06)
- Magura S, Rosenblum A, Rodriguez E. Changes in HIV Risk Behaviors Among Cocaine-Using Methadone Patients. Journal of Addictive Diseases. Vol 17, No. 4, 1998 pp 71-90
- Sprauve M, Lindsay M, Herbert S et al. Adverse Perinatal Outcome in Parturients who use crack cocaine. Obstetrics and Gynecology. Vol 89, No. 5, May 1997 (part 1) pp 674-678
- American college of Obstetricians and Gynecologists. Hypertension in Pregnancy. ACOG. Technical Bulletin # 219. American College of Obstetricians and Gynecologists, Washington, DC, 1996
- Rodriguez E et al. Maternal cocaine use harms infants more than HIV infection. American family physician. Aug 1993, pp 319
- Lopez-Llera, M. Main clinical types and subtypes of eclampsia. American Journal of Obstetrics and Gynecology 1992; 166:4
- Sibai BM. Diagnosis, prevention and management of Eclampsia. Obstetrics and Gynecology 2005:105;402
- Ellerbrock T, Harrington P, Bush T et al. Risk of Human Immunideficiency Virus Infection among Pregnant Crack cocaine users in a rural community. Obstetrics and Gynecology. Vol 86. No. 3 Sept 1995; pp 400-404
- Rodriguez EM, Mofenson LM, Chang BH et al. Association of maternal drug use during pregnancy with maternal HIV culture positivity and perinatal HIV transmission. AIDS. 1996 Mar;10(3):273-282.
- Frank K, Buchmann E, Schackis R. Does Human Immunodeficiency Virus Infection protect against Preeclampsia-Eclampsia? Obstetrics and Gynecology 2004: 104;2: pp 238-242