Cocaine use during pregnancy in the USA has increased dramatically in the past decade, and has resulted in an associated increase in a variety of maternal and perinatal complications. However, a number of confounding factors make it difficult to determine the direct impact of perinatal cocaine use on maternal and fetal outcome. Many substance-abusing women use multiple drugs while pregnant, receive inadequate prenatal care and are predisposed to other health problems that impact on perinatal outcome. As a result of the rapid clearance of cocaine and limitations of available screening methods, the identification of individual users can be difficult. Furthermore, the determination of accurate prevalence rates of cocaine use during pregnancy has been frustrated by sampling bias. Cocaine has profound systemic and cardiovascular effects in both the mother and the fetus, and as a result a number of complications (i.e. fetal malformations, preterm labour, placental abruption) have been attributed to perinatal cocaine exposure. In addition, maternal cocaine use has been associated with a number of neonatal abnormalities, including cardiopulmonary effects, somatic changes and neurobehavioural sequelae. It is estimated that US $500 million dollars in additional health expenditure resulted from increased neonatal hospital costs and longer lengths of stay for cocaine-exposed neonates. This article reviews the reproductive risks associated with prenatal cocaine use. The pharmacology and physiology of cocaine in relation to pregnancy is discussed, and the impact of this substance on the growth and development of the fetus and infant is reviewed.