Although cocaine abuse has declined in popularity in the United States, certain groups continue to use the drug at high rates. The teratogenicity of cocaine has been widely investigated in the newborn. We report a case of crossed renal ectopia in a term neonate whose mother practiced alkaloid cocaine abuse in the first trimester of pregnancy. We propose that this anomaly was caused by cocaine's direct pharmacologic effect, leading to vasoconstriction that affected the developing fetal kidney by compromising the blood vessels that supply the organ or by causing hemorrhages and infarctions with fibrosis, causing disruption during a crucial period of morphogenesis.