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Pregnant Substance Abuser

Essentials

  • Patients often try to conceal or understate their alcohol or illicit drug use; this also applies to mothers attending maternal welfare centres. When discussing substance abuse, one should aim at creating an open and confidential atmosphere. Questions about substance abuse should be direct and the aim should not be to make the patient feel quilty.
  • All pregnant women should be asked about substance abuse.
  • The fetus will be exposed to all substances used by the mother.
  • Withdrawal of substance abuse should be recommended and help offered for it. Appropriate withdrawal and rehabilitation should be initiated without delay as soon as the patient is motivated.
  • A pregnancy in a woman with substance abuse problems is always a high-risk pregnancy, and it is recommended to organize the follow-up to take place, from the very beginning of the pregnancy, within specialized care in cooperation by a multidisciplinary team.
  • The multidisciplinary team consists of representatives from e.g. maternal welfare centre, maternity hospital, addiction treatment centre and child welfare, as well as a paediatrician. Unrestricted flow of information should be established by joint network meetings.
  • Particular attention should be paid to the nutritional status of pregnant women who continue substance abuse, ensuring sufficient intake of vitamins, minerals and trace elements (e.g. folic acid, iron).
  • An anticipatory child welfare notification should be made of a pregnant substance abuser if there is certainty of abuse. Once the baby is born, a strong suspicion of substance abuse is sufficient for making a child welfare notification.

Limits for moderate alcohol consumption

  • Studies have been unable to define an absolute safety limit for maternal alcohol consumption during pregnancy.
  • Binge drinking (4 or more standard drinks equivalent to 12 g of pure alcohol at a time) has been found to be more detrimental than consuming low daily doses.

Identifying excessive alcohol use in antenatal care

  • All pregnant women should routinely be asked about their drinking habits in all units treating them. Various structured screening tools, such as AUDIT Recognition of Alcohol and Drug Abuse (program Audit) may be used.
  • Alcohol use is measured in units or standard drinks. The definition varies widely between countries. In European countries the most common standard drink size is 10 g of pure alcohol. Find out about local definition.
  • Suitable questions to broach the subject include:
    • Is alcohol consumed in your family? Does your partner drink?
    • Have you yourself consumed alcohol during the last year?
    • Have you been drunk during the last year?
    • Have you had a hangover during the last year? Have you drunk alcohol to ease the hangover?
  • A pregnant woman will often report consuming only a little or no alcohol. It is worth asking her to be precise about the meaning of "a little" in alcohol units, i.e. how many bottles of beer or glasses of wine typically at one time and how often: weekly, every day, etc.
  • Information should be given about the risks associated with alcohol consumption during pregnancy (see below).

The risks of alcohol consumption during pregnancy

  • Excessive alcohol consumption during pregnancy is associated with increased risks of
  • Alcohol consumption during pregnancy is the biggest single preventable cause of intellectual disability in western countries.
  • Low-dose alcohol consumption in early pregnancy is not an indication for abortion.

Referral Psychological and/or Educational Interventions for Alcohol or Drug Consumption in Pregnancy

  • In women, a score of HASH(0x2fd8c80) 6 in the AUDIT test requires further examinations.
  • Phosphatidylethanol (blood PEth) testing is a specific blood test indicating alcohol use, and it can be used also during pregnancy.
  • Merely broaching the subject of alcohol consumption has been shown to reduce consumption if the problem is not on the level of addiction. Brief intervention therapies have also been shown to be effective in pregnant women with alcohol abuse problems Brief Interventions for Risky Use of Alcohol.
  • The patient should be readily referred to specialized care, i.e. as soon as concern arises.
  • By telling the patient about the effects that substance abuse can have on the course of the pregnancy and the wellbeing of the fetus, the maternal health centre staff can motivate her for follow-up at the antenatal clinic. The frequency of appointments at the antenatal clinic and other supportive measures indicated should be tailored individually, depending on the patient's circumstances.
  • Psychosocial treatment forms the cornerstone of treating abuse also during pregnancy. There are forms and places of treatment specifically for pregnant women.

Smoking Psychosocial Interventions for Supporting Women to Stop Smoking in Pregnancy, Pharmacological Interventions for Promoting Smoking Cessation during Pregnancy

  • All pregnant women should be asked about smoking, snuff use and passive exposure to cigarette smoke.
  • Smoking during pregnancy is associated with increased risks of
    • miscarriage
    • cleft palate
    • low birth weight and intrauterine growth retardation
    • preterm birth
    • sudden infant death syndrome.
  • Smoking cessation should be recommended and support offered for this Smoking Cessation. Nicotine replacement products can be used also during pregnancy.

Identifying illicit drug use in antenatal care

  • All pregnant women should be asked about illicit drug use. It is most natural to ask about any experiments with drugs immediately following questions about smoking and alcohol consumption.
  • Questions should be asked about experiments with and the use of (in many countries illicit) drugs, such as cannabis, amphetamine, exctacy (MDMA) and cocaine, as well as opioids, such as buprenorphine, one drug at a time. Questions should be asked about the abuse of medicines affecting the CNS.
  • If the woman discloses a history of drug experimentation she should be encouraged to specify the date of last use, how the substance was used (smoking, sniffing, injecting etc.), how often it is used, in what situations etc. Structured questionnaires are also available Recognition of Alcohol and Drug Abuse.
  • A urine drug screen can provide evidence of use. Permission of the subject is needed to take a sample, and a positive finding must always be confirmed to be used for child welfare purposes.

Cannabis

  • Tetrahydrocannabinol (THC) has not been shown to increase the risk of fetal malformations.
  • Birth weight of the baby may be lower than average and the duration of pregnancy shorter than average, but they are still within the limits of normal variation.
  • However, use during pregnancy may increase the risk of disturbances of attention, short-term memory and impulse control in childhood.

Amphetamines, cocaine, other stimulants

  • Stimulants are vasoconstrictors. Their non-medical use is associated with an increased risk of:
    • intrauterine growth retardation and low birth weight
    • preterm birth.
  • Use of cocaine has been found to be associated with an increased risk of premature detachment of the placenta.
  • After birth, neurobehavioural symptoms, such as problems associated with muscle tone or the sleep-wake rhythm may occur.
  • Only little research-based knowledge exists regarding the long-term effect of amphetamines on the born child; effects on cognitive functions have been described.

Opioids Opiate Treatment for Opiate Withdrawal in Newborn Infants, Naloxone for Narcotic-Exposed Newborn Infants

  • The use of opioids, such as buprenorphine, heroin and methadone, has not been shown to be associated with any particular risk of organ malformations.
  • Fetal growth and wellbeing need to be monitored during the last trimester.
  • If the maternal use has continued into very late pregnancy the newborn will often experience withdrawal symptoms, which may require pharmacological treatment.
  • Opioid withdrawal treatment can probably be provided for motivated women regardless of the duration of the pregnancy if the pregnancy is monitored carefully. Recurrent substance withdrawal states are a risk to the health of the foetus.
  • Opioid substitution therapy is recommended for pregnant women Treatment of Drug Addicts. If opioid substitution therapy is started during pregnancy, buprenorphine is probably the product to be preferred from the point of view of the fetus and the newborn baby. However, methadone may be better in preventing relapses and ensure better commitment to the treatment. If the woman is on successful substitution therapy at the onset of pregnancy, the substitution product should probably not be changed.

Referral

  • Should a pregnant woman disclose that less than 1 year has elapsed since her last experiment/use, serious consideration should be given to referral to the maternity hospital outpatient clinic.
  • The role of the specialist clinic is to give the patient information about the effects of drugs on pregnancy and on the fetus, to monitor the growth and wellbeing of the fetus, and to identify any problems associated with the pregnancy.
  • The patient should be motivated to accept substance abuse treatment; it may be carried out on either an out-patient or an in-patient basis as needed. Specific forms of treatment for pregnant women and families are also available.
  • In an ideal case, the abuse problem should be identified and treatment started before pregnancy already, and the pregnancy should be planned, as is the case with any other chronic disease.

    References

    • Cook JL, Green CR, de la Ronde S, et al. Screening and Management of Substance Use in Pregnancy: A Review. J Obstet Gynaecol Can 2017;39(10):897-905. [PubMed]
    • Ordean A, Wong S, Graves L. No. 349-Substance Use in Pregnancy. J Obstet Gynaecol Can 2017;39(10):922-937.e2. [PubMed]
    • Tsakiridis I, Oikonomidou AC, Bakaloudi DR, et al. Substance Use During Pregnancy: A Comparative Review of Major Guidelines. Obstet Gynecol Surv 2021;76(10):634-643. [PubMed]
    • Dejong K, Olyaei A, Lo JO. Alcohol Use in Pregnancy. Clin Obstet Gynecol 2019;62(1):142-155. [PubMed]
    • Tobacco and Nicotine Cessation During Pregnancy: ACOG Committee Opinion, Number 807. Obstet Gynecol 2020;135(5):e221-e229. [PubMed]
    • Metz TD, Borgelt LM. Marijuana Use in Pregnancy and While Breastfeeding. Obstet Gynecol 2018;132(5):1198-1210. [PubMed]
    • Smid MC, Metz TD, Gordon AJ. Stimulant Use in Pregnancy: An Under-recognized Epidemic Among Pregnant Women. Clin Obstet Gynecol 2019;62(1):168-184. [PubMed]
    • Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol 2017;130(2):e81-e94. [PubMed]
    • Jones HE, Kaltenbach K, Heil SH et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med 2010;363(24):2320-31. [PubMed]
    • Minozzi S, Amato L, Jahanfar S, et al. Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev 2020;11:CD006318. [PubMed]