Skin Popping Scars – a Telltale Sign of Past and Present Subcutaneous Drug Abuse

DOI 10.1515/crpm-2012-0056 Case Rep. Perinat. Med. 2012; 1(1-2): 37–39

Amos Grunebaum* and Daniel Skupski Skin popping scars – a telltale sign of past and present subcutaneous drug abuse

Abstract Case Background: Identifying women with past and present drug abuse is an essential aspect of prenatal care. A 33-year-old primiparous pregnant woman was admit- Case: Despite having typical telltale physical signs of ted to the hospital at 38 weeks with a history of premature prior subcutaneous drug injections, a 33-year-old preg- rupture of membranes (PROM) about 5 h before admis- nant woman who had regular prenatal care visits with sion. She received prenatal care from a private obstetrician multiple obstetric care providers was only identified as a from the 6th week of pregnancy. At 34 weeks, she moved drug abuser after a cesarean section, when her skin scars to a different city where she continued prenatal care with were identified by one provider as the result of “skin another private obstetrician. popping” related to injections of illicit drugs before this She did not mention her history of drug use during her pregnancy. prenatal care, and physical examinations done by both Conclusion: This case demonstrates that obstetricians obstetricians were unremarkable. On admission, her cervix must become aware of the telltale signs of drug abuse, was 1 cm dilated, not effaced, with the vertex at −3 station. such as subcutaneous injections (skin popping) with The estimated fetal weight was 3600 g, and the fetal heart illicit drugs leading to scaring of the arms and other parts rate was reassuring. The patient initially refused oxytocin, of the body. but eventually gave informed consent for induction with oxytocin at about 15 h after PROM. Oxytocin was gradually Keywords: Cocaine; drug abuse; pregnancy; skin heroin increased until there were regular uterine contractions. popping; skin scarring Throughout labor, the patient rejected recommendations to have an epidural catheter placed. Approximately 24 h after admission, fetal tachycardia and maternal fever occurred, *Corresponding author: Amos Grunebaum, MD, Weill Medical and the diagnosis of chorioamnionitis was made. At that College of Cornell University, 525 East 68th Street, Suite J-130, New York, NY 10065, USA, Tel.: +1 212–7460714, time, the vertex was still at −3 station and the cervix was Fax: +1 212–2024470, E-mail: [email protected] essentially unchanged. The delivery mode was discussed Daniel Skupski: Weill Medical College of Cornell University, with the patient, and she gave informed consent for cesar- New York, NY, USA ean delivery. She was brought to the operating room and after spinal anesthesia was given, a low-segment cesarean delivery was performed through a Pfannenstiel skin inci- Introduction sion. During the cesarean, scars on both of the patient’s arms (Figures 1–3) were detected by the nursing staff and Illicit use of drugs has been reported to lead to adverse the obstetrician who performed the surgery. The infant pregnancy outcomes such as abruptio placentae, intrau- was of normal size and after assessment by the pediatri- terine growth restriction, and preterm birth, and is also cian was sent to the normal nursery with an uneventful associated with an increased risk of sexually transmitted course. After the conclusion of the cesarean, the patient diseases such as HIV and hepatitis C. was questioned about these scars. She initially said that Women who have used drugs before pregnancy or are she was burned as a child and is now looking for a good using drugs during pregnancy are an elusive population, plastic surgeon. However, when the obstetrician pointed and common beliefs that substance abuse occurs only in out to her that these scars did not look like typical burns, the ethnic minority, the poor, or the young population she immediately admitted that these were scars from prior are inaccurate. Because these women often do not openly drug use through subcuticular cocaine injections (“skin admit to using drugs, they are often not identified by their popping”). The patient said she had been drug free for practitioners and are thus deprived of optimal medical many years and had rejected epidural anesthesia because care. she was concerned about the morphine in the epidural. 38 Grunebaum and Skupski, Skin popping scars in pregnant women

Figure 1 Right forearm with typical scars from skin popping.

Comment act when drugs, usually heroin or “speedballs” (heroin plus cocaine), are injected subcutaneously or intramus- cularly. Skin popping is done for different reasons: some There are several potential differential diagnoses for skin drug abusers may have difficulties injecting intravenously scarring, including keloids, chronic folliculitis, contrac- because of difficulties in finding a vein, while others inject ture scars after burns, hypertrophic scars, and acne scars. subcutaneously because it results in slower drug absorp- Occasionally, malignant tumors such as sarcomas and tion, gives less of a “rush,” may allow the drug to last basal cell carcinomas can resemble keloid or hypertrophic longer, and can also decrease the risk of overdosing. scars. Opiate use in pregnancy seems to be increasing. Euro- In this case, the reason for the scarring was repetitive pean researchers reported an apparent increase in skin subcutaneous injections with heroin and cocaine, also popping [3, 9] in drug users. A search on PubMed found known as skin popping. Skin popping is defined as the 21 citations of skin popping, most of them related to major complications such as abscesses and cellulitis [2, 4], botulism [3, 6, 9, 13], and necrotizing fasciitis [11]. Women seem more likely than men to develop skin and soft tissue infections after skin popping [4]. A breast abscess in a woman as a complication of skin popping has been reported [1].

Figure 2 Close-up of scars from skin popping. Figure 3 Close-up left forearm. Grunebaum and Skupski, Skin popping scars in pregnant women 39

In addition, injecting drugs has been associated with women who do not fit the typical stereotype of a drug user. infections such as HIV, hepatitis B and C, and also with At the first prenatal visit as well as the subsequent visits, a other problems such as rhesus alloimmunization [7]. There cursory examination of her upper extremities would have has been no report of skin popping in a pregnant patient. easily identified the typical scars associated with skin Drug and heroin use in pregnancy has been associa- popping and past heroin use. ted with many adverse effects, including higher rates of Patients with a history of drug use are at increased fetal acidemia and demise, lower Apgar scores, growth risks for several complications, including sexually trans- restriction, increase in prematurity and neonatal death, mitted diseases and cardiac and liver problems such as an increase in attention deficit hyperactivity disorder, and hepatitis C and HIV. When a patient presents with this adverse neurodevelopmental outcomes [8, 12, 14, 15]. In history, special attention should be paid to these complica- addition to the obstetrician and the pediatrician, the anes- tions and patients should be screened for medical compli- thesiologist is also challenged by drug-dependent preg- cations including hepatitis C and HIV. In addition, there is nant women with complications such as difficult intrave- an increased risk of recurrent drug use during pregnancy, nous access and hepa titis C exposures [5]. and this may specifically affect the newborn baby. There- The common perception that substance abuse is fore, patients with a history of drug should be screened for solely a problem of poor, ethnic minority, and young indi- drug use during pregnancy and at the time of delivery. viduals is inaccurate [10]. As this case demonstrates, even In conclusion, the typical physical signs of skin though the patient was repeatedly seen by several differ- popping (Figures 1–3) should have alerted the patient’s ent obstetricians during her pregnancy, her past heroin physicians to her past drug use. use was never identified despite clear telltale signs of skin popping. One reason could be that obstetricians are Received August 7, 2012. Accepted August 24, 2012. Previously not sufficiently trained to identify drug use in pregnant published online September 12, 2012.

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