Overviewofsubstancemisuseinpregnantwomen

Author:GraceChang,MD,MPHSectionEditor:CharlesJLockwood,MD,MHCMDeputy
Editor:KristenEckler,MD,FACOG
ContributorDisclosures
Alltopicsareupdatedasnewevidencebecomesavailableandour peerreviewprocess is
complete.
Literaturereviewcurrentthrough:Dec2016.|Thistopiclastupdated:Jan06,2017.
INTRODUCTIONThe obstetrical provider is in a key position for screening, early
diagnosis, counseling, and initiating treatment of pregnant women who use illicit drugs
(marijuana/hashish,cocaine,heroin,hallucinogens,inhalants,methamphetamine,prescription
psychotherapeuticsusednonmedically)[1].Boththegravidaandherfamilybenefitfrom
factual,nonjudgmentalinformationaboutthematernalandfetalrisksofsubstanceuseand
fromcounselingaboutoptionsforcessation.However,substanceusersmaynotseekprenatal
care because of fear, guilt and shame, as well as concerns about medical and legal
intervention[2].Opioidusersmaynotevenrealizethattheyarepregnantiftheyarenot
planning pregnancy and misinterpret the early signs of pregnancy as opioid withdrawal
symptoms (eg, nausea, vomiting, cramping). Unintended pregnancy is common in these
women;inonestudy,86percentofpregnantopioidusingwomenreportedtheirpregnancy
wasunintended[3].
Pregnantwomenaretypicallyhighlymotivatedtomodifytheirbehaviorinordertohelptheir
unbornchild.InanationalsurveyfromtheUnitedStates,themeanrateofpregnancyrelated
abstinenceamongusersofillicitdrugswas57percent[4].Unfortunately,manyofthese
womenresumedsubstanceuseduringtheyearaftergivingbirth,althoughnottothelevelof
nonpregnantwomenwhowerenotrecentmothers.
DEFINITIONSThefollowingtermsareusedtodistinguishdifferentpatternsofdruguse
for diagnosis and treatment (see "Substance use disorder: Principles for recognition and
assessmentingeneralmedicalcare"):

Use Sporadic consumption of alcohol or drugs with no adverse consequences of that

consumption.

AbuseAlthoughthefrequencyofconsumptionofalcoholordrugsmayvary,someadverse
consequencesofthatuseareexperiencedbytheuser.

PhysicaldependenceAstateofadaptationthatismanifestedbyasubstanceclassspecific
withdrawalsyndromethatcanbeproducedbyabruptcessationorrapiddosereduction
ofasubstance,orbyadministrationofanantagonist[5].

Psychological dependence A subjective sense of a need for a specific psychoactive

substance,eitherforitspositiveeffectsortoavoidnegativeeffectsassociatedwithits
abstinence[5].

Addiction Addictionisaprimary,chronicdiseaseofbrainreward,motivation,memory
and related circuitry [6]. Dysfunction in these circuits leads the individual to
pathologicallypursuerewardand/orreliefbysubstanceuseandotherbehaviors.Itis
characterized by inability to consistently abstain, impairment in behavioral control,
craving, diminished recognition of significant problems with ones behaviors and
interpersonalrelationships,andadysfunctionalemotionalresponse.Itofteninvolves
cyclesofrelapseandremission.
DRUGUSEINTHEUNITEDSTATESIllicitdrugsincludemarijuana/hashish,cocaine
(includingcrack),heroin,hallucinogens,inhalants,andprescriptionpsychotherapeuticsused
nonmedically. Results from the 2015 National Survey on Drug Use and Health, which
interviewedover67,500civiliannoninstitutionalizedpersonsaged12yearsandolderinthe
UnitedStates,revealedmarijuanawasthemostcommonlyusedillicitdrug,followedby(in
decreasing order of frequency) nonmedical use of psychotherapeutics, cocaine, and
hallucinogens[7]Inthenonmedicaluseofpsychotherapeuticsgroup,themostcommonly
useddrugswerepainrelievers,followedbytranquilizers,stimulants,andsedatives.
Wheninterviewed,5.4percentofpregnantwomenstatedthattheyhadusedillicitsubstances
inthepastmonth,andamuchlargerproportionsmokedcigarettes(15.4percent)ordrank

alcohol(9.4percent)[8].Theratesofillicitdruguseamongpregnantwomenbyagegroup
were:age15to17years,14.6percent;age18to25years,8.6percent;age26to44years,3.2
percent.Manywomenusemorethanonesubstance[2].
IntheUnitedStates,asmaternaldrugusehasincreased,sohaveneonataladmissionsfor
treatmentofneonatalabstinencesyndrome(see"Neonatalabstinencesyndrome").Inastudy
of over 650,000 infants born in the United States between 2004 and 2013, neonatal
abstinencesyndromecasesincreasedfrom7to27casesper1000neonatalintensivecare
units(NICU)admissionsandmedianlengthofstayfortheseinfantsincreasedfrom13to19
days[9].ThetotalpercentageofNICUdaysnationwidethatwereattributedtotheneonatal
abstinencesyndromeincreasedfrom0.6to4.0percent,witheightcentersreportingthatmore
than20percentofallNICUdayswereattributedtothecareoftheseinfantsin2013.
SCREENINGFORDRUGUSEMultiplesocietiesandagenciesconsiderscreeningfor
substanceabuseapartofcompleteobstetriccareandrecommendaskingallpregnantwomen
abouttheiruseofalcoholandillicitdrugs[1013].Thisrecommendationisbasedonthe
prevalenceofsubstanceabuseinthepopulation,itsadverseeffects,anddatafrommostly
nonrandomized studies that intervention (education, prenatal care, treatment of substance
abuse)canimprovesomematernalandneonataloutcomes[1420].Screeningfollowedby
interventioncanbecosteffective[21].
Ideally, screening is performed at the initial prenatal visit [10], and repeat screening is
performedperiodicallyduringpregnancy(eg,eachtrimester).Substanceuserscomefromall
socioeconomicstrata,ages,andraces[22,23],therefore,mostuserswillonlybeidentifiedif
specifically asked about the problem. In one report, a prenatal care system that did not
routinely screen for substance abuse identified less than onethird of women who
subsequentlyhadachildremovedfromthehomebecauseofparentalsubstanceabuse[24].
Denialisasignificantbarriertoidentifyingthesepatients.Denialmayexistevenwhenthe
patientisdirectlyaskedaboutdruguseorconfrontedwithbehaviors suspicious foruse.
Pregnantwomenmaynotadmittodrugusebecausetheyhaveguiltaboutitseffectontheir
pregnancy,andfearlegalconsequences,includinginvolvementofchildprotectionagencies
and loss of custody of their children [25]. Some states consider substance abuse during
pregnancytobechildabuseandafewconsideritgroundsforinvoluntarycommitmenttoa
treatmentfacility[26].Providersshouldbeawareoflocallawsandreportingrequirements,
whichvarywidely.

Objectivescreening(eg,urinetesting)overcomessomeofthesebarriers,butismorecostly
andhasotherlimitations.(See'Laboratorytesting'below.)
ScreeningtoolsUseofvalidatedscreeningtoolsisrecommended,buttheoptionsare
limited[10].The4PsPlusScreenforsubstanceuseinpregnancyconsistsofquestionsabout
substance use by the patient (in the past or currently), her parents, and her partner. An
affirmativeresponseshouldtriggerfurtherassessment(see 'Assessmentofscreenpositive
patients' below).However,the4PsPlusScreenisacopyrightedscreeninginstrumentthat
maynotbereproducedinanyformwithoutpermission.
TheCRAFFTSubstanceAbuseScreenforAdolescentsandYoungAdultsisavailableforuse
without restriction.It has hadpreliminary testing amongpregnantyoungadults andwas
foundtobebetterthanthemedicalrecordandtheTACEalcoholscreenforidentificationof
prenatalsubstanceuse[27].DataonusingtheCRAFFTtoolinolderwomenarepending.
Two or more positive responses to the following questions indicate the need for further
assessment:

CHaveyoueverriddeninaCARdrivenbysomeone(includingyourself)whowashighor
hadbeenusingalcoholordrugs?

RDoyoueverusealcoholordrugstoRELAX,feelbetteraboutyourselforfitin?

ADoyoueverusealcoholordrugswhileyouarebyyourselforALONE?

FDoyoueverFORGETthingsyoudidwhileusingalcoholordrugs?

FDoyourFAMILYorfriendsevertellyouthatyoushouldcutdownonyourdrinkingor
druguse?

THaveyouevergotteninTROUBLEwhileyouwereusingalcoholordrugs?
For older women, we use the National Institute on Drug Abuse (NIDA) Quick Screen
question(table1).Whilethescreenwasvalidatedintheprimarycarepopulationandnotin
pregnantwomen,benefitsincludethatitquantifiessubstanceuseandincludesbothillicitand

prescriptiondrugs.
AdditionalscreeningtoolsthatshowpromiseinpreliminarystudiesincludetheTAPStool
(tobacco,alcohol,prescriptionmedications,andsubstanceuse/misuse),theSubstanceUse
RiskProfilePregnancy(SURPP),andtheWayneIndirectDrugUseScreener(WIDUS)[28
31]. Comparative studies are ongoing. Additional screening tools are described in detail
separately.(See"Substanceusedisorder:Principlesforrecognitionandassessmentingeneral
medicalcare".)
AssessmentofscreenpositivepatientsApractical,effectiveapproachforinterviewing
womenaboutsubstanceabuseisrespectfulandsensitiveuseofneutrallywordedquestions.It
ispreferabletobeginwithquestionsaboutlawfulsubstances,suchascigarettesmokingand
alcohol, followed by questions about misuse of overthecounter drugs, such as
pseudoephedrineproductsanddextromethorphanproducts,andthenuseofprescriptiondrugs
(opioid analgesics, sedatives, stimulants, tranquilizers), and, finally, illegal substances
(marijuana,methamphetamine,cocaine,heroin,hallucinogens,andinhalants).
Askaboutthefrequencyofdruguse,lengthofthemostrecentpatternofuse,andtimeoflast
use.Itmaybehelpfultoaskaboutwhere,when,andwithwhomdrugsaremostoftenused.
When appropriate, determine the route of administration: oral, intranasal, subcutaneous
injection("skinpopping"),orintravenous.Ifshehaseverusedaneedletoinjectdrugs,ask
aboutsharedneedles.
Foreachsubstance,askaboutthequantityused(ie,quantityofpowder,unitofsalefroma
dealer).Termsusedfordrugunitsvaryregionally,anditishelpfultobefamiliarwithlocal
drugslangandtoaskforexplanationsofunfamiliarterms.Theamountofmoneyspentona
daily/weekly/monthlybasisfordrugsmayalsobeusedtoquantitatedrugusage.However,
informationaboutthequantityofdruguseisnothelpfulindeterminingifanindividualhas
abuse/dependenceandisnotlikelytobeaccuratelyreported.
Askaboutparticipation inselfhelp programs suchas Narcotics Anonymous (NA),prior
detoxificationoraddictiontreatment,andabstinenceperiods.Whathasbeenhelpfulinthe
pastandwhathasbeentried?Howlongwasthelongestperiodofabstinenceormaintenance
treatmentwithoutusingillicitdrugs?
Risk factors for substance useThe following characteristics may alert obstetrical
providerstoanincreasedriskofsubstanceabuseordependenceinwomenwithnegative
responses to direct questions about drug use [2,4,3235] (see "Substance use disorder:

Principlesforrecognitionandassessmentingeneralmedicalcare"):

Young woman (especially adolescents), unmarried women, and women with lower
educationalachievement

Lateinitiationofprenatalcare

Multiplemissedprenatalvisits

Impairedschoolorworkperformance

A sudden change in behavior, such as somnolence, intoxication, agitation, aggression,

disoriented or erratic behavior. Drug users may also exhibit symptoms of depression,
includinglossofinterestineating,weightloss,andsleepdisturbance.

Highrisk sexual behavior or history of sexually transmitted infections. Women who are
tradingsexfordrugsareatriskfortheseinfections.

Relationalproblems,unstablehomeenvironment

Past obstetrical history of unexplained adverse events, such as miscarriage, growth

restriction,prematurebirth,abruptioplacentae,stillbirth,orprecipitousdelivery

Childrennotlivingwiththemotherorinvolvedwithchildprotectionagencies


History of medical problems associated with drug abuse (eg, cellulitis, skin abscess,
endocarditis, osteomyelitis, suspicious trauma, hepatitis, phlebitis, tuberculosis), physical
signsofdruguse(eg,trackmarks,atrophyofthenasalmucosa,erosionorperforationofthe
nasalseptum),orphysicalsignsofwithdrawal(dilationorconstrictionofpupils,tachycardia,
conjunctivalinjection,sweating,wateryeyes,runnynose,slurredspeech,yawning,unsteady
gait)

Poordentition

Poorweightgain

Diagnosisofamentalhealthdisorder

Familyhistoryofsubstanceabuse

Encounters with law enforcement agencies because of violence or trauma, theft, or

prostitution

Havingapartnerwhoisasubstanceabuser.Thisisparticularlyimportantinfemalepatients
whoareoftenintroducedto,andsuppliedwith,drugsbyamalepartner.
Laboratory testingUniversal laboratory testing for evidence of drug use is not
recommendedbecauseofthelimitationsofthesetests[11].Theuseandlimitationsofdrug
tests are described in detail separately. (See "Substance use disorder: Principles for

recognitionandassessmentingeneralmedicalcare".)
Thereisnoconsensusamongresearchgroupsregardingwhendrugtestsshouldbeusedin
pregnantwomenorthebestmethodforanalyzingbiologicalsamples(urine,blood,hair,
saliva)[36].Urinetestingismostcommon.Possibleclinicalindicationsforlaboratorytesting
inpregnancyinclude:

Previouspositivedrugtest

Monitoringcompliancewithmethadoneorbuprenorphineuse

Abruptioplacenta

Idiopathicpretermlabor

Idiopathicfetalgrowthrestriction

Frequentrequestsforprescriptiondrugsofabuse

Noncompliancewithprenatalcare

Unexplainedfetaldemise
Positivetestsforillicitdrugscanhavelegalandeconomicimplications.Womenshouldbe
informedofthepotentialramificationsofapositivetestresultandshouldgiveinformed
consentpriortotesting;randomtestingisunethical[3739].However,medicallyindicated
drugtestingwithoutwrittenconsentisacceptableinwomenwhoareunconsciousorshow
obvious signs of intoxication and need to be tested in order to provide the appropriate
medicalinterventions.Cliniciansshouldbeawareoftheirstate'srequirementsfortestingand
reportingdrugtestresults.
GENERAL PRINCIPLES OF PRENATAL CARE OF THE SUBSTANCE
USERObstetricalprovidersshouldadheretosafeprescribingpracticesofprescription
drugs and encourage healthy behaviors. They should educate patients about

maternal/fetal/neonatalmorbidityassociatedwithsubstanceuse,identifysubstanceusers,and
beawareoflocalresourcesforconsultationandpatientreferral[26].
Substance use assessment, counseling, and support by a nonjudgmental clinician may
motivatesomewomenwhouseillicitdrugsotherthanopioidstoabstain.Mostothersandall
women dependent on opioids will require referral for indepth assessment followed by
counseling and treatment. (Refer to individual topics on specific substances of abuse:
marijuana,cocaine,amphetamines,nonmedicaluseofprescriptionmedications,etc).
Fewrandomizedtrialshaveevaluatedtheoptimumapproachtomanagementofpregnant
substance abusers [4045]. Observational studies suggest that combining treatment of
substanceabusewithcomprehensiveprenatalcarecanreducethefrequencyofsomematernal
and neonatal complications of maternal substance use [1420]. Components of this care
shouldbeindividualizedbasedonpatientspecificfactors,andmayincludethefollowing
[2,1012]:

Counselabouttherisksassociatedwitheachdrugthemotherisusing.Bothmaternaland
shortandlongtermeffectsonoffspringshouldbediscussed.

(See'Pregnancycomplicationsassociatedwithselecteddrugs'below.)

(See "Cocaineusedisorderinadults:Epidemiology,pharmacology,clinicalmanifestations,
medicalconsequences,anddiagnosis".)

(See "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course,

screening,assessment,anddiagnosis".)

(See"Treatmentofcannabisusedisorder".)

(See "Methamphetamine use disorder: Epidemiology, clinical manifestations, course,

assessment,anddiagnosis".)

(See"Infantsofmotherswithsubstanceusedisorder".)


Encouragethepatienttomoderateand,ideally,discontinueuseofillicitdrugs;however,this
dependsonthespecificdrugandpatternofuse.

Forwomenwithopiatedependence,switchingtomethadoneispreferabletodetoxification,
asitissaferandmoresuccessful.Buprenorphineisanotheroptionwhenopiatesubstitution
therapyisunderconsideration[46].(See "Methadonesubstitutiontreatmentofopioiduse
disorderduringpregnancy".)

Womenonhighdosesofbenzodiazepinesshouldundergomedicaldetoxificationtominimize
orpreventwithdrawalsymptoms.(See"Benzodiazepinepoisoningandwithdrawal",section
on'Withdrawal'.)

Ifavailable,aprogramformanagementofdiscontinuationofcocaineormarijuanamaybe
useful. (See "Treatment of cannabis use disorder" and "Psychosocial interventions for
stimulantusedisorderinadults",sectionon'Interventions'.)

(See"Prescriptiondrugmisuse:Epidemiology,prevention,identification,andmanagement".)

Identifycomorbidconditions,suchaspsychiatricdisorders andphysical/sexual/emotional
abuse,which occurfrequentlyin substanceabusers.The interrelationships betweenthese
issuesandsubstanceuseneedtobeaddressedincaringforthesepatients.

(See "Intimatepartnerviolence:Diagnosisandscreening" and "Intimatepartnerviolence:

Interventionandpatientmanagement".)


(See "Unipolar major depression during pregnancy: Epidemiology, clinical features,
assessment, and diagnosis" and "Bipolar disorder in women: Preconception and prenatal
maintenance pharmacotherapy" and "Bipolar disorder in pregnant women: Treatment of
mania and hypomania" and "Bipolar disorder in pregnant women: Treatment of major
depression"and"Obsessivecompulsivedisorderinpregnantandpostpartumwomen".)

Assembleamultidisciplinaryteamtocomprehensivelyassessandparticipateinthecareof
these women and their offspring. The team may include obstetrical, medical, pediatric,
psychiatric,addictionmedicine,andsocialserviceproviders.

Addresstheneedsofpoorlynourished,homeless,and/orincarceratedpregnantsubstance
abusers.Inadditiontoeducationaboutnutritionandweightgain,someofthesewomenmay
need referral to food assistance programs and shelters, and provision of transportation
vouchersandprenatalmultivitamins.

(See"Prenatalcareforhomelesswomen".)

(See"Prenatalcareforincarceratedwomen".)

(See"Weightgainandlossinpregnancy"and"Nutritioninpregnancy".)

Testforsexuallytransmitteddiseases(eg,syphilis,gonorrhea,chlamydia,hepatitisBandC,
humanimmunodeficiencyvirus)andtuberculosis,whichmaybetransmittedtothefetusor
neonate. These tests should be repeated in the third trimester in women who remain at
increasedrisk.


(See"Initialprenatalassessmentandfirsttrimesterprenatalcare"and"Prenatalcare(second
andthirdtrimesters)",sectionon'Sexuallytransmitteddisease'.)

(See"Syphilisinpregnancy".)

(See"PrenatalevaluationoftheHIVinfectedwomaninresourcerichsettings".)

(See"VerticaltransmissionofhepatitisCvirus".)

(See"Epidemiology,transmission,andpreventionofhepatitisBvirusinfection",sectionon
'Mothertochildtransmission'.)

(See"Tuberculosisinpregnancy".)

Duringprenatalvisits,provideeducationandsupport,monitormaternalandfetalstatus,and
assessforcomplicationsofpregnancyorhealthproblemsrelatedtoaddiction.

Obtain an early ultrasound examination to provide the most accurate determination of

gestationalage,whichisimportantforlaterevaluationoffetalgrowthandaccuratediagnosis
ofpretermversustermorposttermgestation.(See "Prenatalassessmentofgestationalage
andestimateddateofdelivery".)

Assess for fetal growth restriction in the second half of pregnancy. (See "Fetal growth
restriction:Evaluationandmanagement",sectionon'Pregnancymanagement'.)

Perform antepartum fetal surveillance for standard obstetrical indications (eg, growth
restriction,antepartumbleeding,preeclampsia)ormaternalwithdrawal.Substanceusealone

isnotanindicationforfetalmonitoringwithnonstresstestsorthebiophysicalprofile.(See
"Overviewofantepartumfetalsurveillance".)

Consulttheanesthesiaservicepriortodeliverytodevelopapainmanagementplan[47,48].
Womenwithsubstanceabusedisorders,especiallythoseinvolvingopioids,maybemore
sensitivetopain,maynotobtainadequatepainreliefwithusualdosesofpainrelievers,and
mayhavedifficultvenousaccess[49,50].

Inform the pediatric service of the possibility of neonatal withdrawal. (See "Neonatal
abstinencesyndrome".)

Discuss the risks and benefits of breastfeeding. Women who use illicit drugs should
understandthatthesedrugscanbedetectedinbreastmilkandcanaffecttheneonate.(See
"Infants ofmothers withsubstanceusedisorder",sectionon'Breastfeeding'.)Womenon
methadoneorbuprenorphinemaybeencouragedtobreastfeed;however,cautionshouldbe
exercisedifmothersareabusingotherillicitsubstancesand/orbeingtreatedwithmultiple
prescription drugs (see "Methadone substitution treatment of opioid use disorder during
pregnancy", section on 'Breastfeeding'). The American Academy of Pediatrics (AAP)
generallyrecommendsagainstbreastfeedingforwomenonamphetamines[51].
PREGNANCYCOMPLICATIONSASSOCIATEDWITHSELECTEDDRUGSThe
effectofanyillicitdrugonpregnancyoutcomeisdifficulttoascertainbecausedataare
scarceandconfoundedbytheinfluenceofotherfactors,includingpolysubstanceuse,poor
nutrition,poverty,comorbiddisorders,andinadequateprenatalcare.Inaddition,reliable
ascertainment of the extent of drug use during pregnancy and drug dose/purity are
impossible.
Theclinicalmanifestationsofdrugabusearediverse,anddifferbydrugandsetting(eg,
usualdose,overdose,withdrawal).Combinedwiththephysiologicchangesofpregnancyand
the clinical manifestations of coexisting pregnancyrelated disease, diagnosis of patients

presentingwithseriousclinicalabnormalitiescanbechallenging.Forexample,cocaineand
amphetamine overdose can cause hypertension and seizures, similar to
preeclampsia/eclampsia.
OpiatesManyofthemedicalrisksassociatedwithheroinaddictionarethesameforboth
pregnantandnonpregnantwomen,andsimilarforaddictiontootheropiates.Inaddition,
opiate users typically have financial, social, and psychological problems that cause
psychosocialstress,exposethemtoviolence[52],andaffecttheiroptionsandtreatment[2].
(See "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course,
screening,assessment,anddiagnosis"and"Pharmacotherapyforopioidusedisorder".)
Multipleobstetricalcomplicationshavebeenassociatedwithopiatedependenceinpregnancy
[53,54].However,itisdifficulttoestablishtheextenttowhichtheseproblemsaredueto
opiates or opiate withdrawal or other drugs used by polydrug abusers versus coexistent
maternalmedical,nutritional,psychological,andsocioeconomicissues.

Abruptioplacentae

Fetaldeath

Intraamnioticinfection

Fetalgrowthrestriction

Fetalpassageofmeconium

Preeclampsia

Prematurelaboranddelivery

Prematureruptureofmembranes

Placentalinsufficiency

Miscarriage

Postpartumhemorrhage

Septicthrombophlebitis
Neonataloutcomes,includingneonatalabstinencesyndrome,arereviewedseparately.(See
"Infants of mothers with substance use disorder", section on 'Opioids' and "Neonatal
abstinencesyndrome".)
OpioidsubstitutiontherapyForopioiddependentwomen,opioidsubstitutiontherapy
with methadone or buprenorphine offersoverwhelmingadvantagescomparedtocontinued
useofheroin(eg,oraladministration,knowndoseandpurity,safeandsteadyavailability,
improvedmaternal/fetal/neonataloutcomes).Inaddition,itoffersauniqueopportunityto
bringwomenintomedicalandobstetricalcaresystems.Substitutiontherapyispreferableto
medicationassistedwithdrawal(detoxification)becauseitissafeandassociatedwithalower
rateofresumptionofheroinuse[55,56].Clinicaluseofmethadoneandbuprenorphinein
pregnantwomen,aswellasfetal/neonataleffects,arediscussedindetailseparately.(See
"Methadonesubstitutiontreatmentofopioidusedisorderduringpregnancy" and "Neonatal
abstinencesyndrome"and"Infantsofmotherswithsubstanceusedisorder".)
MarijuanaWhilethelimiteddatadonotsupportanincreasedriskofpretermdelivery,
lowbirthweight,orcongenitalanomaliesinwomenwhosmokemarijuanaduringpregnancy,
the American College of Obstetricians and Gynecologists (ACOG) and the Academy of
Breastfeeding Medicine advise avoiding marijuana use during pregnancy and lactation
becauseofconcernsfortheneurodevelopmentalimpactonthedevelopingfetusandchild
[57,58].Marijuana(cannabis)isthemostcommonillicitsubstanceusedduringpregnancy
[57].Prevalenceofmarijuanauseduringpregnancyvariesaccordingtomaternalage,racial
orethnicbackground,andsocioeconomicstatus.Selfreportedratesofusevaryfrom2to5
percent in many studies to approximately 30 percent among young, urban, and
socioeconomicallydisadvantagedwomen[5964].Inaddition,marijuanauseappearstobe
increasingintheUnitedStates,likelyasaresultoflegalizationandchangingsocialattitudes.
Inanationalsurveystudyofover200,000womenaged18to44years,marijuanause(during
thepastmonth)amongpregnantwomenincreased62percentduringthetimeperiod2002to

2014(prevalenceofwomenusingmarijuanainthepastmonthrosefrom2.4in2002to3.9in
2014)[65].Thehighestrateofpregnantwomenreportingmarijuanauseinthepriormonth,
7.5percent,occurredinwomenaged18to25years.Anyincreaseinuseisimportantbecause
approximately50percentofwomenwhousemarijuanawillcontinuetodosowhilepregnant
[66].(See"Cannabisuseanddisorder:Epidemiology,comorbidity,healthconsequences,and
medicolegalstatus".)
Chemicalproductsfrommarijuanausearetransferredacrosstheplacentaandintobreast
milk[6769].Inratmodels,fetalplasmalevelswereapproximately10percentofmaternal
levelsafteracuteexposuretodelta9tetrahydrocannabinol(THC),theprimarypsychoactive
cannabinoid[70].However,repetitiveexposureofTHCresultedinhigherfetallevels.In
comparisonwithanimalmodels,studiesassessingtheimpactofmarijuanauseonhumans
maybeconfoundedbypolysubstanceuse,socioeconomicfactors,andthemultiplechemicals
presentinmarijuanasmoke,whichmaypresentingreaterconcentrations thaninregular
tobaccosmoke[71].Inaddition,contemporarymarijuanaproductshavehigherquantitiesof
THC than during previous decades of study [72]. (See "Cannabis use and disorder:
Pathogenesisandpharmacology".)
Marijuanauseduringpregnancydoesnotappeartonegativelyimpactobstetricsoutcomes,
butdataarelimitedbysmallstudysizeandmultipleconfoundingfactors(eg,tobaccouse,
othersubstanceuse).Inametaanalysisof31studiesthatcomparedbirthoutcomesafter
marijuanauseinpregnancywithnouseduringpregnancy,pooledadjustedanalysisreported
no increased risk for low birth weight (pooled relative risk 1.16, 95% CI 0.981.37) or
pretermdelivery(pooledrelativerisk1.08,95%CI0.821.43)[73].Adjustedconfounding
factorsincludedmaternaltobaccosmoking,othersubstanceuse,andselectedsocioeconomic
anddemographicfactors.Limitationsofthismetaanalysisincludedrelativelyfewwomenin
theriskadjustedgroupandfocusononlytwobirthoutcomes.Similarly,whiletheavailable
datadonotsuggestanincreaseincongenitalanomaliesamongchildrenborntomarijuana
users,thefindingsfromstudiesarelimitedbyrelativelysmallnumbersofwomenwhose
usedonlycannabisandconfounders,suchaslowersupplemental folicacid intakeamong
users[60,7478].
ACOGandtheAcademyofBreastfeedingMedicinealsodiscouragemarijuanauseduring
breastfeeding [57,58]. Additional guidelines, patient information, and resources for
breastfeedingcanbefoundatthewebsiteforthe AmericanCollegeofObstetriciansand

Gynecologists.
Shortandlongtermeffectsofmaternalmarijuanauseonoffspringarereviewedseparately.
(See"Infantsofmotherswithsubstanceusedisorder",sectionon'Marijuana'.)
CocainePublicandprofessionalinterestinprenatalcocaineuseishigh,althoughmany
morepregnantwomensmokecigarettes,drinkalcohol,orsmokemarijuanathanusecocaine
[7984].Femalecrack/cocaineusersintheirthirtiesconstituteafastgrowinggroupofnew
userswhodonotuseothersubstances.(See"Cocaineusedisorderinadults:Epidemiology,
pharmacology,clinicalmanifestations,medicalconsequences,anddiagnosis".)
Cocainereadilycrossestheplacentaandfetalbloodbrainbarrier;vasoconstrictionisthe
majorpurportedmechanismforfetalandplacentaldamage[85].Theputativeconsequences
ofprenatalcocaineexposurehavebeendescribedinhundredsofarticles.Theapplicabilityof
anyofthestudiesislimitedbymethodologicshortcomings,suchasfailuretocontrolfor
maternal age, parity, socioeconomic factors, and exposure to other drugs, alcohol, and
cigarettes.
Thefewadequatelycontrolledreportssuggestthatcocaine'seffectsarerelatedtodoseand
stage of pregnancy. A metaanalysis including 31 studies that evaluated the relationship
between maternal antenatal cocaine exposure and five adverse perinatal outcomes found
cocaineuseduringpregnancysignificantlyincreasedtherisksof[86]:

Pretermbirth(OR3.38,95%CI2.724.21)

Lowbirthweight(OR3.66,95%CI2.904.63)

Smallforgestationalageinfant(OR3.23,95%CI2.434.30)

Shortergestationalageatdelivery(1.47week,95%CI1.97to0.98)

Reducedbirthweight(492grams,95%CI562to421grams)
Othershavereportedincreasedrisksofmiscarriage,abruptioplacentae,anddecreasedlength
(0.71cm)andheadcircumference(0.43cm)atbirth[8789].Teratogeniceffectshavenot
beendefinitivelyproven.(See "Infantsofmotherswithsubstanceusedisorder",sectionon

'Cocaine'.)
Cardiovascular cocaine toxicity is increased in pregnant women [85]. Cocaine toxicity
usuallycauseshypertension,whichmaymimicpreeclampsia.Betaadrenergicantagonists(ie,
beta blockers) should be avoided in the treatment of cocainerelated cardiovascular
complicationsbecausetheycreateunopposedalphaadrenergicstimulationandareassociated
with coronary vasoconstriction and endorgan ischemia. This contraindication includes
labetalol, which has predominantly betablocking effects. Hydralazine is preferred for
treatment of hypertension in pregnant cocaine users [90]. Decisions regarding the
administrationofperipartumanalgesiaoranesthesianeedtobeindividualized,takinginto
accountfactorssuchasthecombinedeffectsofcocaine,analgesia,andanesthesiaonthe
patient'scardiovascularandhematologicalstatus[91].(See "Cocaine:Acuteintoxication"
and "Cocaineusedisorderinadults:Epidemiology,pharmacology,clinicalmanifestations,
medical consequences, and diagnosis" and "Evaluation and management of the
cardiovascularcomplicationsofcocaineabuse".)
Amphetamines including methamphetamineA diagnosis of amphetamine abuse is
becomingmorecommonamongwomenofreproductiveage,includinghospitalizedpregnant
women[9295].Methamphetamine,commonlyknownasspeed,meth,andchalk,orasice,
crystal,andglasswhensmoked,isapowerfullyaddictivestimulant.Itisaknownneurotoxic
agent,whichdamagestheendingsofbraincellscontainingdopamine.Amphetaminesand
their byproducts cross the placenta [96]. No fetal structural abnormalities have been
definitively associated with perinatal amphetamine exposure [97]. However,
methamphetamine exposure during pregnancy has been associated with maternal and
neonatal morbidity and mortality. In studies that controlled for confounders,
methamphetamineexposurewasassociatedwithatwotofourfoldincreaseinriskoffetal
growthrestriction[98100],gestationalhypertension,preeclampsia,abruption,pretermbirth,
intrauterinefetaldemise,neonataldeath,andinfantdeath[101].
Shorttermneonataleffectsandlongtermoutcomesinoffspringarereviewedseparately.
(See"Infantsofmotherswithsubstanceusedisorder",sectionon'Amphetamines'.)
RESOURCES

AmericanSocietyofAddictionMedicine

SubstanceAbuseandMentalHealthServicesAdministration

AmericanCollegeofObstetricsandGynecology
INFORMATION FOR PATIENTSUpToDate offers two types of patient education
materials,TheBasicsandBeyondtheBasics.TheBasicspatienteducationpiecesare
writteninplainlanguage,atthe5thto6thgradereadinglevel,andtheyanswerthefouror
fivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestfor
patientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.These
articlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowant
indepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyouto
printoremailthesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticleson
avarietyofsubjectsbysearchingonpatientinfoandthekeyword(s)ofinterest.)

Basicstopics(see"Patienteducation:Alcoholanddruguseinpregnancy(TheBasics)")
SUMMARYANDRECOMMENDATIONS

Identificationandtreatmentofwomenwhouseillicitdrugscandecreasematernaldruguse
duringpregnancy.Giventhepotentialadversefetalandmaternaleffectsofdruguse,we
recommend screening all pregnant women for drug use (Grade 1C). (See 'Introduction'
aboveand'Screeningfordruguse'above.)

Themostpracticalscreeningmethodistoaskspecificquestionsaboutdruguseusinga
screeningtool.Pregnantwomenmaynotadmitdrugusebecauseofguiltaboutitseffecton
theirpregnancy,andfearlegalconsequences,includinglossofcustodyofchildren.(See
'Screeningfordruguse'aboveand'Screeningtools'above.)

Riskfactorsforincreasedlikelihoodofsubstanceabuseincludelateinitiationofprenatal
care, multiple missed prenatal visits, past adverse obstetrical history, children with
neurodevelopmentalorbehavioralproblems,childrennotlivingwiththemother,historyof
drugoralcoholmediatedmedicalproblems,substanceabuseinapartnerorfamilymember,
andfrequentencounterswithlawenforcementagencies.(See'Riskfactorsforsubstanceuse'
above.)Universallaboratorytestingforevidenceofdruguseisnotrecommendedbecauseof
thelimitationsofthesetests.Possibleclinicalindicationsforlaboratorytestingafterinformed
consent in selected pregnant women include: previous positive drug test, monitoring
compliancewith methadone or buprenorphine use,unexplainedabruptioplacentaorfetal
demise.Cliniciansshouldbeawareoftheirstatesrequirementsfortestingandreportingdrug
testresults.(See'Laboratorytesting'above.)

Fewrandomizedtrialshaveevaluatedtheoptimumapproachtomanagementofpregnant
substanceabusers.Observationalstudiessuggestthatcombiningtreatmentofsubstanceabuse
withcomprehensiveprenatalcarecanreducethefrequencyofsomematernalandneonatal
complicationsofmaternalsubstanceuse.Componentsofthiscareshouldbeindividualized
basedonpatientspecificfactors.(See 'Generalprinciplesofprenatalcareofthesubstance
user'above.)

For women dependent on opiates, we suggest opiate substitution treatment rather than
medicaldetoxificationornotreatment(Grade2C). Methadone or buprenorphine maybe
used; neither drug is clearly superior, but there is more experience with methadone.
Methadoneuseisassociatedwithfewerfetal/neonatalcomplicationsandsideeffectsthan
detoxificationorcontinueduseofunprescribedopiates.(See 'Opioidsubstitutiontherapy'
above.)

Cocaine can cause vasoconstriction of uterine vessels, which is the probable major
mechanismforfetalandplacentalinjuryleadingtoabruptioplacentae,spontaneousabortion,
prematurity,andfetaldeath.(See'Cocaine'above.)


Thereis nohighquality evidenceshowing anadverseeffectofmarijuanaonpregnancy
outcome.Becausedataareconflicting,marijuanauseisdiscouragedduringpregnancyand
lactation.(See'Marijuana'above.)

Definitive information on the impact of exposure to methamphetamine in utero is not

available.(See'Amphetaminesincludingmethamphetamine'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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