EFFECTS OF SMOKING DURING PREGNANCY AND THE EFFECTS ON THE PEDIATRIC PATIENT.

Rachel Alcorn Laura Wooldridge AHEC Community Project May 25, 2007

TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . pg. 3 Effects of smoking during pregnancy. . . . . . . . pg. 3 Toxic chemicals of smoking . . . . . . . . . . . . pg. 5 Infertility. . . . . . . . . . . . . . . . . . . . pg. 6 Malformations of the embryo. . . . . . . . . . . . pg. 7 Spontaneous abortion . . . . . . . . . . . . . . . pg. 7 Placenta previa-accreta. . . . . . . . . . . . . . pg. 8 Placenta abruptio. . . . . . . . . . . . . . . . . pg. 9 Growth restriction and SGA . . . . . . . . . . . . pg. 9 Ectopic pregnancy. . . . . . . . . . . . . . . . . pg. 10 Stillbirth and infant mortality. . . . . . . . . . pg. 11 Maternal smoking and the pediatric patient . . . . pg. 12 Maternal smoking and low birth weight. . . . . . . pg. 12 Risk of cleft lip and palate deformity . . . . . . pg. 13 Nicotine withdrawal and the newborn. . . . . . . . pg. 14 Sudden infant death syndrome . . . . . . . . . . . pg. 15 Smoking as a cause of asthma . . . . . . . . . . . pg. 17 Attention-deficit/hyperactivity disorder . . . . . pg. 19 Smoking cessation in the pregnant patient. . . . . pg. 20 Conclusion . . . . . . . . . . . . . . . . . . . . pg. 21 References . . . . . . . . . . . . . . . . . . . . pg. 22

INTRODUCTION
Approximately 17.6 percent of women between the ages of 15 and 44 years old smoked during their pregnancy last year as stated by the Centers for Disease Control (CDC, 2007). Our purpose in this paper is to discuss the major effects of smoking patient In this tobacco to show we during the aim pregnancy importance to show the in and of in the

pediatric cessation. smoking

smoking how

paper

detail

during

pregnancy

affects

pathological

development of the fetus, the effects of the fetus itself, as well as the long-term effects on the newborn and the child. during We will also and discuss how to safely quit smoking some of the benefits of smoking

pregnancy

cessation on pregnancy and childhood outcomes.

EFFECTS OF SMOKING DURING PREGNANCY

It has long been known that smoking is bad for your health, but when you add a growing fetus to the picture the risks related to tobacco use increase tremendously. One

study states that 27.2 percent of women of reproductive age are smoking. are It is proposed that the the side more effects of

smoking

dose-related,

meaning

cigarettes

smoked daily the higher the risk, however any amount of smoking will raise the probability of complications 3

occurring during and after pregnancy. In addition to the commonly studied side effects of lung disease and bladder cancer, cigarettes can have devastating effects on a

pregnant mother and her baby. The compounds in cigarettes have been found to decrease the fertility of men and women making it harder to conceive. The chemicals also have a profound effect on a growing baby; it has been proven that smoking causes structural and vascular defects leading to spontaneous abortion, placental and fallopian tube changes, intrauterine rupture of growth membranes restriction (PROM). (IUGR) who and choose premature to smoke

Women

during pregnancy are taking a chance with two lives and should be encouraged during to their quit or at least cut et back al.

significantly 2005).

pregnancies

(Hammoud,

Numerous cigarettes

studies

have

shown

that the

the risk

amount of

of

smoked

greatly

increases

side

effects to the mother and the baby. A study found that the rate of preterm delivery in smokers increased from 6.9

percent in women who smoked up to 5 cigarettes daily to 8.9 percent in women who smoked more than 10 cigarettes daily. This trend remains true for IUGR, APGAR scores and PROM. For this reason if the patient is unwilling or unable to quit, it is important to stress the need for them to reduce

the number of cigarettes smoked on a daily basis (Hammoud, et al. 2005).

TOXIC CHEMICALS OF SMOKING

Smoking various is toxic found to in a growing baby The due most to the

compounds

cigarettes.

toxic

chemicals are carbon monoxide, nicotine, cyanide as well as 89 carcinogens. Of the 89 carcinogens some of the common ones include arsenic, benzene, cadmium, chloroform,

formaldehyde, lead, styrene and urethane. These substances have been studied and found to cause various cancers and fetal malformations. Carbon monoxide attaches more readily to hemoglobin and myoglobin than oxygen which decreases the amount of circulating oxygen, as well as stored oxygen, in the body. Decreased oxygen delivery to the fetus causes hypoxia which then inhibits proper growth and development of the fetus. Nicotine easily crosses the placenta and actually reaches levels 15 percent higher in the amniotic fluid and fetus than the mother experiences. With levels of nicotine being increased in the fetus a newborn baby actually experiences nicotine withdrawal.

INFERTILITY
Infertility conceive smoke after a 12 60 is defined of as the inability sex. of Women to who

months

unprotected greater

have

percent

chance

becoming

infertile compared to nonsmokers. These women have a harder time conceiving and maintaining the pregnancy. Smoking

affects the ovaries and interferes with their ability to produce estrogen. This lack of estrogen makes the oocyte more prone to genetic abnormalities. In addition, the

effects of smoking result in an accelerated loss of eggs and early menopause compared to nonsmokers. Augood, Duckett and Templeton have shown that women who smoke enter

menopause 1-1.5 years earlier than those who do not smoke (Augood, et al. 1998). In women vitro who fertilization, smoke need more IVF, studies at have IVF shown to that

attempts

become

pregnant, their ovaries are harder to stimulate, they have fewer eggs, and it is harder for the egg to implant in the uterus. These studies have also shown that women who stop smoking at least two months before attempting conception have an easier time achieving successful conception with IVF. Smoking also affects a mans ability to fertilize an egg. Men have a decreased number of sperm and more

abnormalities

in

their

sperm

as

result

of

smoking

(American Society for Reproductive Medicine, 2003).

MALFORMATIONS OF THE EMBRYO

Harmful environmental stimuli are most detrimental

during the organogenesis stages of pregnancy. Nicotine is a major teratogen that can severely impair proper growth of the embryo because it accumulates in fetal blood and in the amniotic fluid. It has been postulated that nicotine causes cell death in the embryo resulting in spontaneous abortion or fetal malformations. The mechanism of nicotine on the cells leads to oxidative stress which is a major factor in programmed cell death. Therefore, nicotine is causing exposed apoptosis to 3M in of embryonic nicotine cells. When embryos neural are tube

they

develop

defects and have shorter crown-rump lengths. The effects are more pronounced which with increased other amounts of of nicotine

exposure,

confirms

studies

dose-related

effects of nicotine (Zhao, 2005).

SPONTANEOUS ABORTION
Spontaneous abortion is a result of the embryo not implanting or growing properly in the uterus. Smoking has serious vascular effects on the uterus that cause 7

vasoconstriction

of

the

vessels.

The

main

structural

changes in the placenta involve the villous capillaries. The capillaries become tortuous and poorly branched which impedes blood flow and nutrient delivery to the fetus. In addition, vasoconstriction reduces blood flow to the uterus and placenta. Without blood the fetus is unable to get the proper nutrients to grow, which can lead to a spontaneous abortion. causes Decreased blood of flow to the placenta as a actually

hypertrophy

the

placenta

compensatory

mechanism. The trophoblastic basal lamina of the placenta will thicken while the fetal capillaries are reduced in size. The enlarged placenta grows enough to cover the

internal cervical os resulting in placenta previa. Another complication to the placenta is peripheral necrosis due to the decreased blood flow. Necrosis of the outer tissue will weaken the walls Other of the placenta and may result in an

abruption.

structural

changes

include

increased

calcifications and fibrin deposits in placentas exposed to smoke (Van Meurs, 1999).

PLACENTA PREVIA - ACCRETA

Placenta previa is a condition that occurs late in pregnancy. The placenta implants too close to the cervical os and can partially or completely cover the cervical os. 8

Placenta accreta is a condition of the placenta attaching too deeply to the uterine wall but does not penetrate the uterine muscles. It is common to have both placenta previa and accreta occurring at the same time. Both conditions may result in third trimester bleeding, preterm delivery and death to fetus and mother. The risks of developing either condition increases with smoking during pregnancy. The

incidence of placenta accreta was 12.2 percent compared to 4.8 percent in nonsmokers due to the hypertrophy of the placenta. The risk of placenta previa and accreta increases with each subsequent pregnancy because of scarring which leads to fewer implantation sites (Usta, et al., 2005).

PLACENTA ABRUPTIO
Placenta abruptio is the condition of premature

separation of the placenta from the uterus. This causes painful bleeding during the third trimester. For each year of smoking the risk of abruption increases by 40 percent and 25 out of 100 cases of abruptio are linked to smoking (Usta, et al., 2005).

GROWTH RESTRICTION AND SGA

As discussed earlier, fetal hypoxia can lead to IUGR. The average birth weight of a term baby is 2500 grams. A 9

baby that has been exposed to cigarettes weighs an average of 90-200g lighter at term than babies who are not exposed. Pringle, et al shows that weight, length and head

circumference were all decreased at birth in babies exposed to smoking in found utero no compared to non-exposed reduction length noted at at in 20 30 babies. head, weeks weeks

Ultrasound abdominal gestation;

significant or fetal

circumference however, the

changes

were

gestation and were still evident at birth. They also found that insulin-like growth factor was significantly lower in cord plasma of babies exposed to smoke. The placental

weight was also reduced in the babies. This reduction was dose dependant; mothers who smoked 20 cigarettes daily had placentas that were 400 grams lighter than mothers who did not smoke (Pringle, et al., 2005).

ECTOPIC PREGNANCY
Ectopic pregnancies are the primary cause of death in the first of trimester ectopic of pregnancy to the mother. Common

causes disease, However, smoke,

pregnancies and in a

are

pelvic of

inflammatory infertility. of women who

tubal with

surgeries the

history the

increase

number

there

have

also been increases in the number of

10

ectopic pregnancies. As discussed earlier the components of cigarettes have many negative effects. These toxins also have an effect on tubal motility as discussed by Handler, Davis, Ferre and Yero. They measured wave amplitude of tubal contractions before and after

smoking and found that nicotine exposure caused decreased uterotubal activity and longer periods of inactivity. In addition to the effects the nicotine has on tubal activity, the idea that smoking also reduces immunity has brought up questions about the increase in pelvic inflammatory disease and the effects it has on tubal infections. Overall it was found that smoking increases the risk of ectopic

pregnancies twofold compared to nonsmokers and the amount of risk is dose related (Handler, et al., 1989).

STILLBIRTH AND INFANT MORTALITY

Still birth occurs when a fetus dies in utero or

during labor and is then delivered. The chances of having a still birth double with nicotine exposure in the womb. The mechanism of death is most likely due to growth retardation as a result of hypoxia from excess carbon monoxide in the blood. chances Women of who stop a smoking birth greatly and if decrease they can their stop

having

still

smoking by their 16th week of pregnancy 25 percent of all 11

still

births

could

be

prevented

(American

Society

for

Reproductive Medicine, 2003).

MATERNAL SMOKING AND THE PEDIATRIC PATIENT

The effects of maternal smoking on the infant can lead to many abnormalities including low birth weight, cleft

palate, nicotine withdrawal and an increased incidence of sudden infant death syndrome (SIDS), asthma and attentiondeficit/hyperactivity disorder (ADHD). Many of these

problems occur due to the chemistry of nicotine and how it affects the vasculature in utero and the effects it has on the development of the lungs and neurotransmitters in the brain.

MATERNAL SMOKING AND LOW BIRTH WEIGHT

Smoking during pregnancy can double a womens risk of having a baby at low birth weight and 12 percent of babies born to smokers were of low weight (less than 2500 grams). As discussed earlier maternal smoking during pregnancy can cause lower intrauterine birth growth in restriction the newborn. which Low can birth lead to

weights

weight

infants account for 7.6 percent of all live births and most of these are caused by smoking. Many of these infants will

12

die since approximately 69 percent of all infant deaths are due to low birth weight (Law, 2003). Nicotine causes vasoconstriction of the arteries in

the body which leads to decreased flow and is the major cause of myocardial infarction and cerebral vascular

accidents in the United States. Low birth weight is caused by the same pathology. going of the There to is the a decreased amount to of the

oxygenated

blood

placenta when the

due mother

vasoconstriction

arteries

smokes

which leads to poorer nutrition and inability to grow in utero. These infants do no develop fully, having increased risks for future problems including sudden infant death

syndrome and asthma.

RISK OF CLEFT LIP AND PALATE DEFORMITY

Cleft lip and palate are the fourth most common birth defects in the world and account for 1 of every 700

newborns. During fetal development the palate is normally formed during the fourth to seventh weeks of gestation with fusion occurring at the ninth week of gestation. When this closure fails, a cleft palate or lip results. This is

characterized by an incomplete fusion of the lip or hard palate which disables the infant in their ability to

breathe and eat. If left uncontrolled, long term speech and 13

hearing loss can occur. Cleft palate babies will require approximately 10 to 20 surgeries throughout their lives to have full function of their mouths; even then they will still have scarring and most likely be left with a speech impediment (Chung, 2000). Studies have shown that the more cigarettes the mother smokes the higher the risk for cleft palate deformity,

again the dose-dependent theory. The thought is behind how the chemicals in the cigarettes alter the transforming growth

growth

factor-alpha

gene

variants.

Transforming

factors are important because they play crucial roles in the development of embryonic tissues, epithelial cells,

tissue regeneration and regulation of the immune system. When the chemicals of the cigarettes alter the transforming growth factors, it delays or inhibits the growth of the embryonic tissues in utero and leads to malformations of the infant (Shaw, 1996).

NICOTINE WITHDRAWAL IN THE NEWBORN

A mother who smokes during pregnancy has many things to worry about with her child; however, nicotine withdrawal most likely is not one of them. Just as in cocaine, heroin and alcohol use during pregnancy the fetus builds up an addiction to these chemicals. When the chemicals are 14

suddenly taken away the infant starts to crave them and go through withdrawal. Some of the withdrawal symptoms the infant will encounter are insomnia, headache, stomach pain, constipation and gas. These can all lead to a very unhappy and inconsolable infant. When it comes to the heavier drugs more severe forms of withdrawal proceed, as in seizures and electrolyte

abnormalities. When an infant becomes addicted to nicotine the results are similar for why it is so hard for people to quit smoking. The number of nicotinic receptors in the

brain are increased immensely which leads for more and more of them requiring nicotine to stay calm. When they do not receive the nicotine, the infant becomes more agitated and excitable. When mothers smoke the chemicals cross the placenta and act as vasoconstrictors reducing uterine blood flow by up to 38%. This results in fetal hypoxia and brain and neuronal damage (Law, 2003). This is also the cause of the infant having a higher risk of attention-

deficit/hyperactivity disorder, which is discussed later.

SUDDEN INFANT DEATH SYNDROME

Sudden infant death syndrome, or SIDS, is defined as death of an infant unexplainable by postmortem exam. SIDS 15

is fairly common, being two of every 1000 children born in the United States. This commonly occurs in children under 6 months of age, more commonly between the hours of 4AM-6AM and is the most commonly unexplained cause of death before the age of one (Auth, 2006). The actual cause of SIDS is unknown; however, there are many hypothesized reasons with the main one being the inability to wake oneself when hypoxia occurs. When infants feel they are out of oxygen and stop breathing, receptors in the brain trigger what is called autoresuscitation. When this fails the infant is unable to awaken and take a breath. One of the major risk factors for impaired

autoresuscitation is the effects of nicotine and how it raises the arousal threshold in the infant so they are

unable to wake up, turn their head and gasp for air. This risk is greatly increased with second hand smoke continued in the home after nicotine exposure in utero (Thompson, 2006). Other risks factors of SIDS include sleeping in the prone position, low birth weight, low socioeconomic status, drug-addicted mothers and family history of SIDS. Even with these other risk factors smoking cessation while pregnant and after birth, studies have shown a great decrease in the incidence of SIDS.

16

SMOKING AS A CAUSE OF ASTHMA IN THE PEDIATRIC PATIENT

Asthma is a major cause of hospital emergency room visits in the young patient. Asthma is a reversible type lung disease that of is caused by a triad of obstruction, airways and inflammation. There is

hypersensitivity

initially inflammation of the smooth muscle layer of the trachea, response then to large some travel amounts of and mucus as a the are secreted in and of

allergen to the

eosinophils amount

lymphocytes

area,

greater

obstruction occurs leading to an asthma attack. It leads is to well acute known asthma that secondary cigarette of smoking

attacks

because

bronchial

irritation and inflammation. Asthma can be caused by other triggers such as household allergens, pollen, mold, mildew, extreme temperatures and pet dander. However, recent

studies have shown that mothers who smoke during pregnancy cause a higher risk for their child to acquire asthma

usually within the first 3 years of life. It was found that Children with any in utero exposure to maternal smoking were at increased risk of asthma (Li, 2005). Many of these children that are exposed to tobacco in utero are also exposed in their homes after birth; however, one study has proven that the risk of in utero tobacco exposure and environmental exposure are independent 17

variables in the cause of asthma and both are of equal risks in causing asthma. As explained in the American

Journal of Respiratory and Critical Care Medicine, smoking during pregnancy causes many dangerous carcinogens to cross the placenta and harm the development of the lungs

(Gilliland, 2001). The lungs start to develop around 6-8 weeks gestation before and in a healthy This full-term at the fetus are

completed

birth.

means

critical

developmental times, if the mother is smoking the ability for the lungs to mature correctly is hindered. This leads to lower surfactant levels which decreases the ability of the lungs to expand and contract. The alteration of

development leads to lower lung function in general and increased bronchial hyperactivity (Gilliland, 2001). The factors that cause asthma are bronchial

irritation, inflammation, and spasm. It makes sense that over activity of the smooth muscles due to the chemical exposure from smoking is a high risk factor for asthma. Therefore, tobacco smoke is not only a trigger for an

asthma attack it is also linked with the cause of asthma. In the research it is estimated that if mothers did not smoke while pregnant there would be an overall reduction in asthma by approximately 15 percent (Gilliland, 2001).

18

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER AND SMOKING

Attention-deficit/hyperactivity disorder, or ADHD, is on the rise in the United States. ADHD is defined as a pattern of behavior but where the child a is mix inattentive of the or

hyperactive,

most

commonly

two.

Inattentive type features short attention span, inability to listen or follow instruction, forgetfulness, inability to organize and easily distracted. Hyperactive type is

classified as being fidgety, difficulty staying seated or waiting in line, impulsive speech and inability to remain quiet. There must be six of the above symptoms for

classification and they must last at least 6 months with the diagnosis before 7 years old (Auth, 2006). There are many speculations of what is causing this disorder in children, as in parental neglect, lack of

discipline and other environmental factors. One theory is that mothers who smoke while pregnant increase the risk of ADHD. Studies risk have for shown having that there is with a threefold hyperkinetic

increased

offspring

disorder with mothers who smoked while pregnant compared with those who did not (Schmitz, 2006). The physiology

behind these facts is that nicotine reduces cerebral blood flow to the brain which leads to a low birth weight,

microcephaly and abnormalities in the neuronal matter of 19

the body and result in lower IQs. This in turn is expressed as a hyperactive child that is unable to pay attention in class and mentally does not have the capability of higher level thinking. These children also have a higher number of nicotinic receptors in the brain, as do adults who smoke and are much more easily agitated than a child not exposed to nicotine in utero (Schmitz, 2006).

SMOKING CESSATION IN THE PREGNANT PATIENT

As discussed in this paper there is a high importance in smoking cessation of the pregnant patient. This needs to be a goal set as early as possible in the pregnancy or when planning a pregnancy. The first process as with all other smokers who are trying to quit; the 5 As which are Ask, Advise, thoughts Assess, of Assist, and Arrange. advise First on the ask about

smoking

cessation,

long-term

effects to the infant and mother, assess the willingness to quit, assist the mother in quitting and arrange for a stop date and other help that may be necessary. However, the help that we can actually give other than emotional support and counseling to the pregnant mother may be greatly limited. Studies have not shown whether the risk or benefit is higher in using nicotine replacement in the pregnant patient. The American College of Obstetricians and 20

Gynecologists, ACOG, recommends that nicotine patches and gum should only been used in the pregnant patient when

counseling has failed and nicotine nasal spray and inhaler should be avoided since it is a Category D and may cause harm to the developing fetus. Bupropion should again only be used if counseling has failed; this is a Category B drug and has not been shown to cause actual harm to a human fetus (Bailey, 2002). of With the these limited patient techniques strong, in

smoking

cessation

pregnant

early

counseling is the first line therapy.

CONCLUSION
Smoking during pregnancy has multiple consequences on the outcome of the the child. From time of conception to early chemicals found in cigarettes play an

childhood,

integral part in the development and well-being of fetus and child. Multiple studies have consistently shown that cigarettes infertility, abortion, cause complicated previa pregnancies and and which include

placenta

abruption, later delays

spontaneous lead to

fetal

malformations

can and

fetal/infant

deaths,

developmental

childhood

asthma. In many cases smoking cessation before conception or in early gestation will avoid many of the harmful

effects discussed in this paper. 21

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attention-deficit/hyperactivity disorder, predominantly inattentive type: A case-control study. Journal of American Academy of Child and Adolescent Psychiatry. 45 (11) 13381345. Shaw, G.M., Wasserman, C.R., Lammer, E.J., OMalley, C.D., Murray, J.C., Basart, A.M., Tolarova, M.M. 1996. Orofacial clefts, parental cigarette smoking, and transforming growth factor-alpha gene variants. American Journal of Human Genetics. 58 (3) 551-561. Van Mears, K. 1999. Cigarette smoking, pregnancy and the developing fetus. Stanford University School of Medicine 1(1). Usta, I.M., Hobeika, E.M., Abu Musa, A.A., Gabriel, G.E., Nassar, A.H. 20005. Placenta previa-accreta: Risk factors and complications. American Journal of Obstetrics and Gynecology. 193. 1045-1049 Zhao, Z., Reece, A.E. 2005. Nicotine-induced embryonic malformations mediated by apoptosis from increasing intracellular calcium and oxidative stress. Birth defects research (part B)74. 383-391.

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