This document discusses substance misuse during pregnancy and provides information on various substances including alcohol, tobacco, cannabis, cocaine, methamphetamines, opioids, and others. It outlines the risks these substances pose to both the mother and developing fetus, including low birthweight, preterm birth, birth defects, neonatal abstinence syndrome, and long term developmental effects. The document recommends screening all pregnant women for substance use and providing treatment and support through behavioral interventions.

1. DR ALKA MUKHERJEE
NAGPUR M.S. INDIA
SUBSTANCE MISUSE IN
PREGNANCY

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause Society,
India, Indian medico-legal & ethics association(IMLEA), ISOPRB,
HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. KEY LEARNING POINTS
• All pregnant women should be asked about alcohol or substance
misuse
• Multi-agency care is key to improved outcomes
• Consider the effects of substances on the developing fetus.
• Prenatal substance use - critical public health concern - linked
with several harmful maternal and fetal consequences.
• The most frequently used substance in pregnancy is tobacco,
followed by alcohol, cannabis and other illicit substances.
• Unfortunately, polysubstance use in pregnancy is common, as well
as psychiatric comorbidity, environmental stressors, and limited
and disrupted parental care,
• Treatments for prenatal substance use and these mainly comprise
behavioral and psychosocial interventions.
• Contingency management

4. INTRODUCTION
• The incidence of most substance misuse in pregnancy is unknown.
It can be divided into non-illicit (e.G. Alcohol)and illicit (cannabis,
heroin and other opiates, cocaine, ecstasy, ketamine, etc.)
Substances.
• Many substances pass easily through the placenta - reach the
fetus.
• Recent research shows that smoking tobacco or marijuana, taking
prescription pain relievers, or using illegal drugs during pregnancy
is associated with double or even triple the risk of stillbirth.
• 5 percent of pregnant women use one or more addictive
substances.
• All pregnant women at their antenatal booking visit should be
asked questions about alcohol consumption and use of illicit drugs
to identify women who may need enhanced care during and after
pregnancy.

5. NAS
• Regular use of some drugs can cause neonatal abstinence
syndrom (NAS), in which the baby goes through withdrawal upon
birth.
• use of alcohol, barbiturates, benzodiazepines, and caffeine during
pregnancy may also cause the infant to show withdrawal
symptoms at birth.
• The type and severity of an infant's withdrawal symptoms depend
on
• the drug(s) used,
• how long and
• how often the birth mother used,
• how her body breaks the drug down, and
• whether the infant was born full term or prematurely

6. •How Drugs Cross the Placenta
Some of the fetus's blood vessels are contained in tiny hairlike projections (villi) of
the placenta that extend into the wall of the uterus. The mother's blood passes
through the space surrounding the villi (intervillous space). Only a thin membrane
(placental membrane) separates the mother's blood in the intervillous space from
the fetus's blood in the villi. Drugs in the mother's blood can cross this membrane
into blood vessels in the villi and pass through the

7. How a drug affects a fetus depends on
•The fetus's stage of development
•The strength and dose of the drug
•The genetic make-up of the mother, which affects how much
of the drug is active and available
•Other factors related to the mother (for example, if the
mother is vomiting, she may not absorb as much of a drug, so
the fetus is exposed to less of the drug)

8. Heavy alcohol use in pregnancy
• The evidence for low to
moderate alcohol use in
pregnancy has either been
inconclusive or shown no
increased risk for these adverse
pregnancy outcomes
• The development of fetal alcohol
spectrum disorders and adverse
neurodevelopmental outcomes
• In addition, prenatal drinking is
associated with long-term
effects, such as cognitive and
behavioral challenges adverse
speech and language outcomes
executive functioning deficits in
children and
• Psychosocial consequences in
adulthood
Heavy alcohol use in pregnancy
has been associated with a
range of negative birth
outcomes, including:
• Increased risks of
miscarriage
• Stillbirth and infant
mortality
• Congenital anomalies
• Low birthweight
• Reduced gestational age,
• Preterm delivery and
• Small-for-gestational age

9. • Fetal alcohol exposure occurs when a woman drinks while
pregnant. Alcohol can disrupt fetal development at any stage
during a pregnancy—including at the earliest stages before a
woman even knows she is pregnant.
• Nursing should take place at least 2 hours after drinking to
allow the alcohol to be reduced or eliminated from the
mother's body and milk. This will minimize the amount of
alcohol passed to the baby.

10. Smoking during pregnancy
• Smoking during pregnancy exerts direct adverse effects on birth outcomes,
including
 Damage to the umbilical cord structure
 Miscarriage
 Increased risk for ectopic pregnancy
 Low birthweight
 Placental abruption
 Preterm birth
 And increased infant mortality
• Deleterious health effects of second-hand smoke on newborns, which include
 Higher rates of respiratory and ear infections,
 Sudden infant death syndrome,
 Behavioural dysfunction and cognitive impairment
 Additionally, women who were smokers before pregnancy might stop
breastfeeding early so that they can take up smoking again

11.  Carbon monoxide and nicotine from tobacco smoke may interfere with
the oxygen supply to the fetus.
 Nicotine also readily crosses the placenta, and concentrations of this
drug in the blood of the fetus can be as much as 15 percent higher than
in the mother.
 Sudden infant death syndrome (sids),
 Learning and behavioral problems and an increased risk of obesity in
children. In addition, smoking more than one pack a day during
pregnancy nearly doubles the risk that the affected child will become
addicted to tobacco if that child starts smoking.
 Even a mother's second hand exposure to cigarette smoke can cause
problems; such exposure is associated with premature birth and low
birth weight, for example
 Research provides strong support that nicotine is a gateway drug,
making the brain more sensitive to the effects of other drugs such as
cocaine

12. • Similar to pregnant women, nursing mothers are also advised
against using tobacco.
• New mothers who smoke should be aware that nicotine is passed
through breast milk, so tobacco use can impact the infant's brain
and body development—even if the mother never smokes near
the baby. There is also evidence that the milk of mothers who
smoke smells and may taste like cigarettes.
• Secondhand Smoke
• Newborns exposed to secondhand smoke are at greater risk for
SIDS, respiratory illnesses (asthma, respiratory infections, and
bronchitis), ear infections, cavities, and increased medical visits
and hospitalizations.
• If a woman smokes and is planning a pregnancy, the ideal time to
seek smoking cessation help is before she becomes pregnant.

13. Risks of Stillbirth from Substance Use in
Pregnancy
• Tobacco use—1.8 to 2.8 times greater risk of stillbirth, with
the highest risk found among the heaviest smokers
• Marijuana use—2.3 times greater risk of stillbirth
• Evidence of any stimulant, marijuana, or prescription pain
reliever use—2.2 times greater risk of stillbirth
• Passive exposure to tobacco—2.1 times greater risk of
stillbirth
• Source: Tobacco, drug use in pregnancy, 2013

14. Risks of Sudden Infant Death (SIDS)
• Children born to mothers who both drank and smoked
beyond the first trimester of pregnancy have a twelvefold
increased risk for sudden infant death syndrome (SIDS)
compared to those unexposed or only exposed in the first
trimester of pregnancy.
• New information from the NIH Safe Passage Study calls for
stronger public health messaging regarding the dangers of
drinking and smoking during pregnancy.

15. NICE clinical guidance makes several recommendations to enhance care for
pregnant women who misuse substances, including:
• Offer referral to a substance misuse programm
• Offer information and support about:
 Additional services available to her (e.G. Drugs and alcohol
support services),
 Potential effects of the drug(s) on her baby and
 What to expect when the baby is born (medical care required,
where the baby will be cared for, involvement of social services),
and
 Help with transport to attend appointments.
 Remind about appointments, using various methods (e.G. Texting)

16. Caffeine during pregnancy
• Consuming caffeine during pregnancy harms the fetus is unclear.
• Evidence seems to suggest that consuming caffeine in small amounts (for
example, one cup of coffee a day) during pregnancy poses little or no risk
to the fetus.
• Caffeine, which is contained in coffee, tea, some sodas, chocolate, and
some drugs, is a stimulant that readily crosses the placenta to the fetus.
• Some evidence suggests that drinking more than seven cups of coffee a
day may increase the risk of having
 Stillbirth,
 Premature birth,
 Low-birth-weight baby, or
 Miscarriage.
• Some experts recommend limiting coffee consumption and drinking
decaffeinated beverages when possible.

17. Aspartame during pregnancy
• Aspartame, an artificial sweetener, appears to be safe during
pregnancy when it is consumed in small amounts, such as in
amounts used in normal portions of artificially sweetened
foods and beverages. For example, pregnant women should
consume no more than 1 liter of diet soda a day.

18. Bath salts during pregnancy
• Bath salts refers to a group of designer drugs made from
various substances that resemble amphetamine. More and
more pregnant women are using these drugs.
• The drugs may cause the blood vessels in the fetus to
narrow, reducing the amount oxygen the fetus gets.
• Also, these drugs increase the risk of the following:
 Stillbirth
 Premature detachment of the placenta (abruptio placentae)
 Possibly birth defects

19. Cannabis/ Marijuana
• Preterm labor,
• Low birthweight,
• Small-for-gestational age, and
• Admission to the neonatal intensive care unit
• Prenatal cannabis use has also been linked with adverse consequences for the
growth of fetal and adolescent brains ,
• Reduced attention and executive functioning skills,
• Poorer academic achievement and
• More behavioral problems .
• The adverse effects of marijuana are frequently observed with comorbid
substance use, and are greatest in heavy users.
• A 2017 opinion posted by the American College of Obstetrics and Gynecology
(ACOG) more pronounced effects in women who consume marijuana
frequently, especially in the first and second trimesters. ACOG recommends that
pregnant women or women contemplating pregnancy should be encouraged to
discontinue use of marijuana for medicinal purposes in favor of an alternative
therapy for which there are better pregnancy-specific safety data.

20. Cocaine use during pregnancy,
• Preterm birth,
• Low birthweight, and
• Small for gestational age infants
• Can be long-term effects of prenatal
cocaine exposure on language, motor, and
cognitive development,
• Babies smaller head circumferences,
• shorter in length
• symptoms of irritability, hyperactivity,
tremors, high-pitched cry, and excessive
sucking at birth.
• These symptoms may be due to the
effects of cocaine itself, rather than
withdrawal, since cocaine and its
metabolites are still present in the baby's
body up to 5 to 7 days after delivery.
• That pregnant women who use
cocaine are at higher risk for
maternal migraines and seizures,
premature membrane rupture,
and placental abruption
(separation of the placental
lining from the uterus).
• Pregnancy is accompanied by
normal cardiovascular changes,
and cocaine use exacerbates
these changes—sometimes
leading to serious problems with
high blood pressure
(hypertensive crisis),
spontaneous miscarriage,
preterm labor, and difficult
delivery.
BABY MOTHER

21. Methamphetamine use
• Linked with shorter gestational ages, lower birthweight, fetal loss,
developmental and behavioral defects, preeclampsia, gestational
hypertension, and intrauterine fetal death.
• Pregnant women who use methamphetamine have a
• Greater risk of preeclampsia (high blood pressure and possible
organ damage)
• Premature delivery, and
• Placental abruption.
• Their babies are more likely to be smaller and to have low birth wt
• exposed children - increased emotional reactivity and
anxiety/depression, more withdrawn, had problems with
attention, and showed cognitive problems that could lead to
poorer academic outcomes.

22. AMPHETAMINE ADDICTION
• Colloquially: speed, amphetamine sulfate, phet, billy, whizz,
sulph, base, paste, dexamphetamine, dexies, Dexedrine ® .
• Swallowed, smoked, snorted, or injected
• Associated with
 Growth restriction,
 Preterm delivery,
 Heart defects,
 Central nervous system (cns)defects,
 Talipes (especially with ectasy),
 Cleft lip and palate

23. ECSTASY (MDMA, 3,4-
METHYLENEDIOXYMETHAMPHETAMINE)
• Limited data on effects on fetus
• Possible increased risk of congenital abnormalities
• Theoretical risks from vaso-constrictive effects

24. Opioid use in pregnancy
• Greater risk of low birthweight,
• Respiratory problems,
• Third trimester bleeding,
• Toxemia and mortality.
• Maternal opiate use is associated with an increased risk of neonatal
abstinence syndrome (nas), whereby opiate exposure in utero triggers a
postnatal withdrawal syndrome
• Nas results in substantial neonatal morbidity and increased healthcare
utilization
• S/s OF NAS- irritability, feeding difficulties, tremors, hypertonia, emesis,
loose stools, seizures, and respiratory distress
• Opioid exposure in pregnancy has also been associated with postnatal
growth deficiency, microcephaly, neurobehavioral problems, and sudden
infant death syndrome. Cigarette smoking, which is very common in
pregnant women with an opioid use disorder (77–95%)

25. MDMA (Ecstasy, Molly)-may cause learning, memory,131 and
motor problems in the BABY
Heroin
• Heroin use during pregnancy can result in neonatal
abstinence syndrome (NAS) specifically associated with
opioid use.
• NAS occurs when heroin passes through the placenta to the
fetus during pregnancy, causing the baby to become
dependent on opioids. Symptoms include excessive crying,
high-pitched cry, irritability, seizures, and gastrointestinal
problems, among others.

26. Drugs Used During Labor and Delivery
• Drugs used to relieve pain during pregnancy (such as local
anesthetics and opioids) usually cross the placenta and can
affect the newborn.
• For example, they can weaken the newborn's urge to
breathe. Therefore, if these drugs are needed during labor,
they are given in the smallest effective doses.

27. Treatment of substance use in pregnancy
Contingency
management
(CM)
Based on the principle of positive
reinforcement as a means of operant
conditioning to influence behavior
change. The premise behind CM is to
systematically use reinforcement techniques,
usually monetary vouchers,
to modify behavior in a positive and
supportive manner. Originally used for the
treatment of cocaine users, it has
since been used for opioids, marijuana,
cigarettes, alcohol, benzodiazepines, and
other drugs.
Description of behavioral interventions for substance use disorders.

28. Motivational
interviewing
(MI)
A patient-centered, collaborative and
highly empathic counselling style for
eliciting behavior change by helping
clients to explore and resolve
ambivalence. It draws from the trans
theoretical model of change in order to
improve treatment readiness and
retention.

29. Cognitive
Behavioral
Therapy (CBT)
A psychotherapeutic treatment that uses an
easy-to-learn set of strategies to help
patients understand the
situations that lead them to undesirable
thoughts, feelings, or behaviors, to then
avoid those situations when
possible, and to deal more effectively with
such situations when they occur. The goal of
these strategies is to
break old patterns of responding and
replace them with new ones.

30. • Work with social care professionals to provide supportive
and coordinated care, which can address a woman’s fears
about children’s services involvement and the potential
removal of her child, and address her feelings of guilt about
her substance misuse and the potential effects on her baby.

31. ALCOHOL MISUSE
• Several questionnaire tools are available for screening—a
very simple tool is the CAGE questionnaire which comprises
discriminating questions where two affirmative questions
strongly predicts alcoholism

32. ALCOHOL ADDICTION
• Women drinking >6 U of alcohol daily are at greatest risk of
fetal alcohol syndrome
• Incidence varies between 0.33 and 1.9/1000 births
• Fetal alcohol syndrome is associated with growth restriction,
hand and facial deformities, and intellectual impairment
• More than two ‘glasses’ of alcohol a day may lead to fetal
alcohol effects—problems with learning speech, language,
attention span, and hyperactivity.

33. SPECIFIC PREGNANCY ISSUES
• Consultant-led care with specialist team
• Detailed anomaly scan, followed by serial growth scans
• Screen for liver disease and clotting disorders;
• Consider other health issues (e.G. Oesophageal varices,
blood-borne infections).

34. HEROIN ADDICTION
• Colloquially: boy, brown, china white, dragon, gear, H, horse,
junk, skag, smack.
• Heroin is a class A drug. Smoked, sniffed, or injected as a
solution.
• Not teratogenic
• Pregnancy associations are preterm delivery, fetal growth
restriction, antepartum haemorrhage (APH), and multiple
pregnancy
• Replacement therapy: methadone or buprenorphine
(Subutex ).

35. SPECIFIC PREGNANCY ISSUES
• The aim is to ‘stabilize’ opiate addiction with a replacement
therapy
• Women often (falsely) believe they have to be opiate-free to
keep their baby and so may try to reduce replacement
therapy without medical supervision
• Women should be told that the most important issue is to
engage with maternity and social services and not to reduce
replacement therapy without medical supervision

36. • Reduction of methadone/buprenorphine is very difficult
during pregnancy; rapid reduction can lead to more
problems such as withdrawal, risk-taking behavior, and an
increase in the use of street drugs
• Some women may require more methadone or Subutex ® as
pregnancy progresses.

37. Care pathway for substance
misuse in pregnancy
At first contact with maternity
services, enquire about
use of alcohol and recreational
drugs, and, if identified,
offer referral to substance misuse
program

38. Multi-agency integrated care
delivery Involving the
multidisciplinary team of
obstetrician, midwife, pediatric
liaison team, drug/alcohol
services, social worker or
probation officer, GP and
health visitor, mental health
services, dietician

39. An integrated care plan should be developed covering
the topics:
• Attendance for antenatal care
• Attendance at other specialist services
• Maternal health, including mental health
• Fetal development and well-being—scan for growth
restriction
• Current smoking/alcohol/drug/use
• Involvement and support of partner
• Stability of lifestyle/social circumstances/domestic
violence/homelessness

40. Current or potential risk
• Preparation for labour and delivery
• Preparation for post-natal period and for
parenthood
• Future needs to be addressed
• Child protection issues.
Post-natal care
• Continue multidisciplinary support, if necessary
• Implement post-natal plan
• Monitor drug/alcohol use
• Ensure appropriate contraception after birth—
consider long-acting reversible contraception.