Rachel Alcorn Laura Wooldridge AHEC Community Project May 25, 2007


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


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.INTRODUCTION Approximately 17.2 percent of women of reproductive age are smoking. during We will also and discuss how to safely quit smoking some of the benefits of smoking pregnancy cessation on pregnancy and childhood outcomes. the effects of the fetus itself. but when you add a growing fetus to the picture the risks related to tobacco use increase tremendously.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. meaning cigarettes smoked daily the higher the risk. 2007). however any amount of smoking will raise the probability of complications 3 . EFFECTS OF SMOKING DURING PREGNANCY It has long been known that smoking is bad for your health. as well as the long-term effects on the newborn and the child. smoking smoking how paper detail during pregnancy affects pathological development of the fetus. are It is proposed that the the side more effects of smoking dose-related. One study states that 27.

placental and fallopian tube changes. The chemicals also have a profound effect on a growing baby. A study found that the rate of preterm delivery in smokers increased from 6. (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. cigarettes can have devastating effects on a pregnant mother and her baby.occurring during and after pregnancy. APGAR scores and PROM. pregnancies (Hammoud.9 percent in women who smoked up to 5 cigarettes daily to 8. intrauterine rupture of growth membranes restriction (PROM). For this reason if the patient is unwilling or unable to quit. This trend remains true for IUGR. The compounds in cigarettes have been found to decrease the fertility of men and women making it harder to conceive. Numerous cigarettes studies have shown that the the risk amount of of smoked greatly increases side effects to the mother and the baby. In addition to the commonly studied side effects of lung disease and bladder cancer. it is important to stress the need for them to reduce 4 .9 percent in women who smoked more than 10 cigarettes daily. it has been proven that smoking causes structural and vascular defects leading to spontaneous abortion. significantly 2005).

These substances have been studied and found to cause various cancers and fetal malformations. 2005). et al. toxic chemicals are carbon monoxide. as well as stored oxygen. Decreased oxygen delivery to the fetus causes hypoxia which then inhibits proper growth and development of the fetus. formaldehyde. nicotine.the number of cigarettes smoked on a daily basis (Hammoud. Nicotine easily crosses the placenta and actually reaches levels 15 percent higher in the amniotic fluid and fetus than the mother experiences. Of the 89 carcinogens some of the common ones include arsenic. benzene. 5 . styrene and urethane. chloroform. TOXIC CHEMICALS OF SMOKING Smoking various is toxic found to in a growing baby The due most to the compounds cigarettes. cadmium. Carbon monoxide attaches more readily to hemoglobin and myoglobin than oxygen which decreases the amount of circulating oxygen. With levels of nicotine being increased in the fetus a newborn baby actually experiences nicotine withdrawal. cyanide as well as 89 carcinogens. in the body. lead.

smoke need more IVF.INFERTILITY Infertility conceive smoke after a 12 60 is defined of as the inability sex. These women have a harder time conceiving and maintaining the pregnancy. studies at have IVF shown to that attempts become pregnant. their ovaries are harder to stimulate. et al. Smoking also affects a man’s ability to fertilize an egg. they have fewer eggs. 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. In women vitro who fertilization. In addition. Augood. of Women to who months unprotected greater have percent chance becoming infertile compared to nonsmokers. the effects of smoking result in an accelerated loss of eggs and early menopause compared to nonsmokers. Duckett and Templeton have shown that women who smoke enter menopause 1-1. Men have a decreased number of sperm and more 6 . Smoking affects the ovaries and interferes with their ability to produce estrogen. and it is harder for the egg to implant in the uterus. This lack of estrogen makes the oocyte more prone to genetic abnormalities.5 years earlier than those who do not smoke (Augood. 1998).

nicotine is causing exposed apoptosis to 3µM in of embryonic nicotine cells.abnormalities in their sperm as a result of smoking (American Society for Reproductive Medicine. 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. When embryos neural are tube they develop defects and have shorter crown-rump lengths. confirms studies dose-related effects of nicotine (Zhao. The effects are more pronounced which with increased other amounts of of nicotine exposure. Smoking has serious vascular effects on the uterus that cause 7 . MALFORMATIONS OF THE EMBRYO Harmful environmental stimuli are most detrimental during the organogenesis stages of pregnancy. SPONTANEOUS ABORTION Spontaneous abortion is a result of the embryo not implanting or growing properly in the uterus. Therefore. The mechanism of nicotine on the cells leads to oxidative stress which is a major factor in programmed cell death. 2005). 2003). It has been postulated that nicotine causes cell death in the embryo resulting in spontaneous abortion or fetal malformations.

Another complication to the placenta is peripheral necrosis due to the decreased blood flow. structural changes include increased calcifications and fibrin deposits in placentas exposed to smoke (Van Meurs. The main structural changes in the placenta involve the villous capillaries. Necrosis of the outer tissue will weaken the walls Other of the placenta and may result in an abruption. 8 . The placenta implants too close to the cervical os and can partially or completely cover the cervical os. PLACENTA PREVIA . vasoconstriction reduces blood flow to the uterus and placenta. The trophoblastic basal lamina of the placenta will thicken while the fetal capillaries are reduced in size. which can lead to a spontaneous abortion. Without blood the fetus is unable to get the proper nutrients to grow. In addition. The capillaries become tortuous and poorly branched which impedes blood flow and nutrient delivery to the fetus.ACCRETA Placenta previa is a condition that occurs late in pregnancy. 1999).vasoconstriction of the vessels. The enlarged placenta grows enough to cover the internal cervical os resulting in placenta previa. causes Decreased blood of flow to the placenta as a actually hypertrophy the placenta compensatory mechanism.

2005).8 percent in nonsmokers due to the hypertrophy of the placenta. et al. The incidence of placenta accreta was 12. A 9 . GROWTH RESTRICTION AND SGA As discussed earlier. The average birth weight of a term baby is 2500 grams. preterm delivery and death to fetus and mother.2 percent compared to 4. 2005). et al. It is common to have both placenta previa and accreta occurring at the same time. Both conditions may result in third trimester bleeding. The risks of developing either condition increases with smoking during pregnancy. fetal hypoxia can lead to IUGR. The risk of placenta previa and accreta increases with each subsequent pregnancy because of scarring which leads to fewer implantation sites (Usta.Placenta accreta is a condition of the placenta attaching too deeply to the uterine wall but does not penetrate the uterine muscles.. 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. PLACENTA ABRUPTIO Placenta abruptio is the condition of premature separation of the placenta from the uterus.

The placental weight was also reduced in the babies. However. weeks weeks Ultrasound abdominal gestation. significant or fetal circumference however. Common causes disease. et al shows that weight.baby that has been exposed to cigarettes weighs an average of 90-200g lighter at term than babies who are not exposed. mothers who smoked 20 cigarettes daily had placentas that were 400 grams lighter than mothers who did not smoke (Pringle. They also found that insulin-like growth factor was significantly lower in cord plasma of babies exposed to smoke.. et al. ECTOPIC PREGNANCY Ectopic pregnancies are the primary cause of death in the first of trimester ectopic of pregnancy to the mother. of women who tubal with surgeries the history the increase number there have also been increases in the number of 10 . Pringle. This reduction was dose dependant. the changes were gestation and were still evident at birth. 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. pregnancies and in a are pelvic of inflammatory infertility. smoke. 2005). head.

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. 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 . As discussed earlier the components of cigarettes have many negative effects.. The chances of having a still birth double with nicotine exposure in the womb. In addition to the effects the nicotine has on tubal activity. 1989). The mechanism of death is most likely due to growth retardation as a result of hypoxia from excess carbon monoxide in the blood. et al. Ferre and Yero. STILLBIRTH AND INFANT MORTALITY Still birth occurs when a fetus dies in utero or during labor and is then delivered. These toxins also have an effect on tubal motility as discussed by Handler. Davis. 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. 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.ectopic pregnancies.

6 percent of all live births and most of these are caused by smoking. 2003). 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. which Low can birth lead to weights weight infants account for 7. Many of these infants will 12 . asthma and attentiondeficit/hyperactivity disorder (ADHD). cleft palate. MATERNAL SMOKING AND THE PEDIATRIC PATIENT The effects of maternal smoking on the infant can lead to many abnormalities including low birth weight. As discussed earlier maternal smoking during pregnancy can cause lower intrauterine birth growth in restriction the newborn. MATERNAL SMOKING AND LOW BIRTH WEIGHT Smoking during pregnancy can double a women’s 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). nicotine withdrawal and an increased incidence of sudden infant death syndrome (SIDS).still births could be prevented (American Society for Reproductive Medicine.

having increased risks for future problems including sudden infant death syndrome and asthma. When this closure fails. This is characterized by an incomplete fusion of the lip or hard palate which disables the infant in their ability to breathe and eat. 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. 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. 2003). 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. These infants do no develop fully. If left uncontrolled. a cleft palate or lip results. 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.die since approximately 69 percent of all infant deaths are due to low birth weight (Law. long term speech and 13 . Low birth weight is caused by the same pathology.

2000). Transforming factors are important because they play crucial roles in the development of embryonic tissues. nicotine withdrawal most likely is not one of them. tissue regeneration and regulation of the immune system. The thought is behind how the chemicals in the cigarettes alter the transforming growth growth factor-alpha gene variants. Cleft palate babies will require approximately 10 to 20 surgeries throughout their lives to have full function of their mouths.hearing loss can occur. heroin and alcohol use during pregnancy the fetus builds up an addiction to these chemicals. it delays or inhibits the growth of the embryonic tissues in utero and leads to malformations of the infant (Shaw. 1996). even then they will still have scarring and most likely be left with a speech impediment (Chung. When the chemicals of the cigarettes alter the transforming growth factors. NICOTINE WITHDRAWAL IN THE NEWBORN A mother who smokes during pregnancy has many things to worry about with her child. Studies have shown that the more cigarettes the mother smokes the higher the risk for cleft palate deformity. again the dose-dependent theory. When the chemicals are 14 . however. epithelial cells. Just as in cocaine.

When they do not receive the nicotine. Some of the withdrawal symptoms the infant will encounter are insomnia.suddenly taken away the infant starts to “crave” them and go through withdrawal. as in seizures and electrolyte abnormalities. constipation and gas. This results in fetal hypoxia and brain and neuronal damage (Law. 2003). When an infant becomes addicted to nicotine the results are similar for why it is so hard for people to quit smoking. SIDS 15 . which is discussed later. 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 mothers smoke the chemicals cross the placenta and “act as vasoconstrictors reducing uterine blood flow by up to 38%”. the infant becomes more agitated and excitable. When it comes to the heavier drugs more severe forms of withdrawal proceed. is defined as death of an infant unexplainable by postmortem exam. These can all lead to a very unhappy and inconsolable infant. stomach pain. SUDDEN INFANT DEATH SYNDROME Sudden infant death syndrome. or SIDS. headache. This is also the cause of the infant having a higher risk of attention- deficit/hyperactivity disorder.

drug-addicted mothers and family history of SIDS. This risk is greatly increased with second hand smoke continued in the home after nicotine exposure in utero (Thompson. studies have shown a great decrease in the incidence of SIDS. 2006). however. low socioeconomic status. This commonly occurs in children under 6 months of age. Even with these other risk factors smoking cessation while pregnant and after birth. 16 . 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. receptors in the brain trigger what is called “autoresuscitation”. When this fails the infant is unable to awaken and take a breath.is fairly common. being two of every 1000 children born in the United States. there are many hypothesized reasons with the main one being the inability to wake oneself when hypoxia occurs. 2006). Other risks factors of SIDS include sleeping in the prone position. more commonly between the hours of 4AM-6AM and is the most commonly unexplained cause of death before the age of one (Auth. When infants feel they are out of oxygen and stop breathing. turn their head and gasp for air. The actual cause of SIDS is unknown. low birth weight.

one study has proven that the risk of in utero tobacco exposure and environmental exposure are independent 17 . pollen. airways and inflammation. Asthma is a reversible type lung disease that of is caused by a triad of obstruction. Asthma can be caused by other triggers such as household allergens. However. There is hypersensitivity initially inflammation of the smooth muscle layer of the trachea. Many of these children that are exposed to tobacco in utero are also exposed in their homes after birth.SMOKING AS A CAUSE OF ASTHMA IN THE PEDIATRIC PATIENT Asthma is a major cause of hospital emergency room visits in the young patient. 2005). It leads is to well acute known asthma that secondary cigarette of smoking attacks because bronchial irritation and inflammation. It was found that “Children with any in utero exposure to maternal smoking were at increased risk of asthma” (Li. mold. mildew. 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. greater obstruction occurs leading to an asthma attack. 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. however. extreme temperatures and pet dander.

Therefore.variables in the cause of asthma and both are of equal risks in causing asthma. 2001). 18 . 2001). inflammation. The alteration of development leads to lower lung function in general and increased bronchial hyperactivity (Gilliland. 2001). tobacco smoke is not only a trigger for an asthma attack it is also linked with the cause of asthma. smoking during pregnancy causes many dangerous carcinogens to cross the placenta and harm the development of the lungs (Gilliland. As explained in the American Journal of Respiratory and Critical Care Medicine. The lungs start to develop around 6-8 weeks gestation before and in a healthy This full-term at the fetus are completed birth. if the mother is smoking the ability for the lungs to mature correctly is hindered. 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. means critical developmental times. 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. This leads to lower surfactant levels which decreases the ability of the lungs to expand and contract. The factors that cause asthma are bronchial irritation.

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER AND SMOKING Attention-deficit/hyperactivity disorder. difficulty staying seated or waiting in line. impulsive speech and inability to remain quiet. as in parental neglect. The physiology behind these facts is that nicotine reduces cerebral blood flow to the brain which leads to a low birth weight. ADHD is defined as a pattern of behavior but where the child a is mix inattentive of the or hyperactive. 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. inability to organize and easily distracted. 2006). Hyperactive type is classified as being fidgety. or ADHD. is on the rise in the United States. Inattentive type features short attention span. inability to listen or follow instruction. forgetfulness. most commonly two. One theory is that mothers who smoke while pregnant increase the risk of ADHD. lack of discipline and other environmental factors. microcephaly and abnormalities in the neuronal matter of 19 . 2006). There are many speculations of what is causing this disorder in children. 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.

of Assist. The American College of Obstetricians and 20 . Advise. as do adults who smoke and are much more easily agitated than a child not exposed to nicotine in utero (Schmitz. assist the mother in quitting and arrange for a stop date and other help that may be necessary. However. These children also have a higher number of nicotinic receptors in the brain. thoughts Assess. The first process as with all other smokers who are trying to quit. 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.the body and result in lower IQs. long-term effects to the infant and mother. assess the willingness to quit. Studies have not shown whether the risk or benefit is higher in using nicotine replacement in the pregnant patient. This needs to be a goal set as early as possible in the pregnancy or when planning a pregnancy. 2006). SMOKING CESSATION IN THE PREGNANT PATIENT As discussed in this paper there is a high importance in smoking cessation of the pregnant patient. the help that we can actually give other than emotional support and counseling to the pregnant mother may be greatly limited. and Arrange. the 5 A’s which are Ask. advise First on the ask about smoking cessation.

2002). of With the these limited patient techniques strong. in smoking cessation pregnant early counseling is the first line therapy. cause complicated previa pregnancies and and which include placenta abruption. 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.Gynecologists. developmental childhood asthma. Multiple studies have consistently shown that cigarettes infertility. ACOG. this is a Category B drug and has not been shown to cause actual harm to a human fetus (Bailey. Bupropion should again only be used if counseling has failed. abortion. integral part in the development and well-being of fetus and child. From time of conception to early chemicals found in cigarettes play an childhood. later delays spontaneous lead to fetal malformations can and fetal/infant deaths. In many cases smoking cessation before conception or in early gestation will avoid many of the harmful effects discussed in this paper. CONCLUSION Smoking during pregnancy has multiple consequences on the outcome of the the child. 21 .

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