Substance-abuse-during-pregnancy (ELearningPage)

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      <HtmlField Name="References"><![CDATA[<ol>
    <li>Alcohol GBD, drugs Use C. The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. "008;5(12):987-1012.</li>
    <li><a href="http://www.who.int/substance_abuse/publications/pregnancy_guidelines/en/">Organization WH. Guidelines for identification and management of substance use and substance use disorders in pregnancy 2014.</a></li>
    <li>Behnke M, Smith VC: Comittee on Substance Abuse and Comittee on Fetus and Newborn. Prenatal substance abuse: Short- and long-term effects on the exposed fetus. Pediatrics. 2013;131(3):e1009-24.</li>
    <li>Abraham M, Alramadhan S, Iniguez C, Duijts L, Jaddoe VW, Den Dekker HT, et al. A systematic review of maternal smoking during pregnancy and fetal measurements with meta-analysis. PLoS One. 2017;12(2):e0170946.</li>
    <li>Wozniak JR, Riley EP, Charness ME. Clinical presentation, diagnosis, and management of fetal alcohol spectrum disorder. Lancet Neurol. 2019;18(8):760-70.</li>
</ol>]]></HtmlField>
      <HtmlField Name="Author"><![CDATA[<p>Marte Jettestad, Dept. Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway</p>
<p>Merete Hein, Medical director of Family Center, Aarhus University Hspital, Denmark</p>
<p>Kahila Hanna, Dept. Obstetrics and Gynevology Helsinki University Hospital, Helsinki, Finland</p>]]></HtmlField>
      <HtmlField Name="TakeHomeMessage"><![CDATA[<ul>
    <li>All drugs pass the placenta and to breast milk in different amounts. Every fetus and neonate has its own vulnerability for drug induced growth restriction, neonatal abstinence syndrome and long-term effect. Thus, all medications and drugs should be kept to a minimum during pregnancy and lactation.</li>
    <li>Every women as well as her partner should be asked about use of alcohol, tobacco, drugs and medications irrespective of their socio-economic status or nationality.</li>
    <li>Many of the most commonly abused substances have a short half-life in the blood, but can be detected in urine for an extended period.</li>
    <li>Alcohol is the leading cause of preventable developmental disabilities.</li>
    <li>Pregnant substance abusers have a significantly higher frequency of both somatic and psychological morbidity.<br />
    <br />
    </li>
</ul>]]></HtmlField>
      <HtmlField Name="PageContent"><![CDATA[<h2>Introduction</h2>
<p>Worldwide alcohol and substance abuse causes a substantial burden of disease. WHO has estimated that some 31 million persons have a substance abuse disorder. The patterns and extent vary substantially between countries, and are strongly associated with social development.</p>
<div style="background-color: #e6e1dc; padding: 32px;"><em>WHO definition of abuse: <br>
&rdquo;Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. Psychoactive substance use can lead to dependence syndrome - a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.&rdquo;</em> </div>
<p>Substance abuse is a psychiatric disorder that should be approached with the same prudence as any other medical disorder. In Europe, it is estimated that a quarter of drug abusers are women. Typically neglect and abuse in childhood make women vulnerable to developing drug problems and which, in the absence of adequate support, can contribute to a downward spiral. The women are often reluctant to seek care for fear of negative judgment or hostile reaction from service staff and there is a need for specialized supportive services for drug-using mothers.</p>
<p>Pregnancy and motherhood can be strong motivating forces to help women face up to and work towards the restoration of health of affected individuals. Pregnant substance abusers have a significantly higher frequency of somatic and psychological morbidity. In addition to poor overall health and nutritional status, the degree of the impact of drug use during pregnancy largely depends on the intensity of drug use. Often, more than one substance is abused and polysubstance use is likely to cause synergistic effects on offspring. Therefore these women belong to a high-risk group that needs closer follow-up than usually recommended, both during pregnancy and after birth. </p>
<p>There are local drug habits and you should know the typical sociodemographic drug habits of your area. </p>
<p>Every woman as well as her partner should be asked about possible abuse of alcohol, tobacco and drugs when entering maternity care. She should be provided with evidence-based information on the effects of substance use during pregnancy. If there is a suspected problematic use of substances she should be referred to a special antenatal care service for pregnant women with substance use problems. If there is solid evidence of substance use during pregnancy (positive urine drug screening or health care visits when intoxicated) the health care staff should notify the local welfare services before delivery.</p>
<p>Many of the most commonly abused substances have a short half-life in the blood, but can be detected in urine for an extended period. However, phosphatidylethanol (PEth) in serum offers a highly sensitive and specific biomarker of alcohol use the previous last weeks. </p>
<h2>General effects of substance abuse on the fetus</h2>
<p>All drugs pass the placenta and over into the breast milk in different amounts. Depending on the amount and frequency of abuse, the risk of adverse fetal outcomes such as spontaneous abortion, preterm labor/delivery and decreased fetal weight, head circumference and length. To which extent this applies by different substances is not yet fully known.Often research findings have not been adjusted for gestational age and preterm labor/delivery is defined differently. Common confounders are smoking, maternal age and time and type of drug abuse before and during pregnancy. Also consensus is needed in the scientific community on how neurodevelopment should be assessed, at what age and for how long the follow-up period should last for neurodevelopmental conditions. This includes assessing a wide variety of outcomes important for the child's daily functioning, including motor skills, cognition, behavior and emotionality, with valid and reliable measures from infancy through to adolescence (3). Every fetus and child also has individual vulnerability; what is tolerated in one can lead to brain damage in another. In general, all drugs, illegal, legal, prescribed or not prescribed, should be kept to a minimum without affecting the mother-infant dyad.&nbsp;</p>
<p>
Neonatal abstinence syndrome (NAS) is a term usually confined to a discussion about opiates. But all substances, including prescribed medications like SSRIs and alcohol, can cause different types of neonatal abstinence symptoms. Neonatal abstinence can last from days to months. </p>
<p>In term neonates breastfeeding should be encouraged to help increase parenting skills and decrease stress responses and an increase in the vagal tone of the neonate, indicating better autonomic regulation. Healthcare workers and parents should be aware of maternal somnolence and a lack of adequate sleep-wake cycling. Decreased reaction times due to alcohol or drug use may increase the risk of infant injury, including sudden infant death syndrome (SIDS) and smothering the child by falling asleep while breastfeeding. <br>
<br>
More information about the use of prescription medication can be found at: <a href="www.relis.no">RELIS</a>, <a href="www.janusinfo.se">Janusinfo</a>, <a href="mailto:konsultaatiot.teratologinen@hus.fi">e-mail.</a></p>
<h2>Smoking</h2>
<p>Maternal smoking is one of the most important preventable factors associated with adverse pregnancy outcome. Cigarette smoke contains more than 3000 toxic components. Both smoking and passive smoking increases the risk of infertility, growth restriction, placental abruption, preterm rupture of membranes (PPROM) and placenta previa. To quit smoking, or reduce the number of cigarettes/e-cigarettes/ pouches of snuff used on a daily or regular basis is helpful throughout the pregnancy, as in particular smoking in third trimester inhibits fetal growth. Mothers smoking more than 10 cigarettes per day are at greatest risk.</p>
<p>Nicotine substitutes such as chewing gum and patches can be used if this helps the woman to quit smoking. Some studies indicate a possible neonatal nicotine withdrawal syndrome with symptoms of neonatal eating problems, irritability and tremors. Studies have also shown an association between fetal exposure to tobacco smoke and diseases in adulthood such as asthma, obesity, high blood pressure, ADHD and gestational diabetes. </p>
<h2>Alcohol</h2>
<p>Alcohol is the most common drug of abuse and up to 60-85% of women consume alcohol during their reproductive age.&nbsp;In WHO 2018 released SAFER, an initiative to help reducing harmful use of alcohol and improve related health, social and economic consequences. Eastern Europe had the highest age-standardized attributable burden for alcohol, followed by southern sub-Saharan Africa. </p>
<p>Alcohol is the most toxic drug for a fetus. Several countries do not disapprove moderate alcohol intake, while others, like Norway, encourage total abstinence. </p>
<p>There is no amount of alcohol intake that has been documented to be safe. Health care providers should ask for drinking habits at the first maternity consultation from every pregnant woman. &ldquo;TWEAK&rdquo; is a useful assessment tool. <br>
<br>
T&mdash;Tolerance*&mdash;&ldquo;How many drinks can you tolerate?&rdquo; <br>
W&mdash;Worried&mdash;&ldquo;Have close friends or relatives worried or complained<br>
about your drinking in the past year?&rdquo;<br>
E&mdash;Eye-opener&mdash;&ldquo;Do you sometimes take a drink in the morning when you first get up?&rdquo;<br>
A&mdash;Amnesia&mdash;stands for blackouts&mdash;&ldquo;Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?&rdquo;<br>
K&mdash;K/Cut Down&mdash;&ldquo;Do you sometimes feel the need to cut down on your drinking?&rdquo;<br>
<br>
Most pregnant women reduce their alcohol consumption during pregnancy without help from the health services, but as many as 40% do not practice total abstinence. Because alcohol can have a detrimental effect on the fetus throughout pregnancy, it is valuable to quit drinking alcohol at all stages of pregnancy.</p>
<h2>Fetal alcohol spectrum disorder (FASD)</h2>
<p>Alcohol is the leading cause of preventable developmental disabilities. Depending on the amount of alcohol the mother consumed and the vulnerability of the fetus, fetal alcohol disorder has many symptoms. These include abnormalities in physical, mental, and behavioral development (such as fetal/child growth restriction; mental retardation; attention deficit and disruptive behavior disorders; specific learning difficulties; poor motor coordination) with varied degrees of severity in an individual. FASD is a group of conditions and should be considered as a continuum of symptoms rather than a specific diagnosis. The most severe is Fetal Alcohol Syndrome (FAS) with facial abnormalities, including wide-set and narrow eyes, growth problems and nervous system abnormalities.</p>
<p>There is no knowledge about the lower safe limit of alcohol consumption during pregnancy. Several observational studies have shown that high alcohol consumption (more than 2 units per day) and binge drinking is associated with FAS; while other studies find that one unit of alcohol a week during pregnancy is sufficient to increase the risk for behavioral problems in the child. Children may develop behavioral problems such as learning difficulties and remembering, understanding and following orders, executive functions, attention, controlling emotions, communicating and socializing and daily life skills. FASD may not be diagnosed before the age of 7-10 years. There is a reason to believe that many studies with shorter follow-up give a false safety margin.</p>
<h2>
Illicit drugs </h2>
<h3>Cannabis (hashish, marijuana)</h3>
<p>Cannabis is one of the drugs with the longest established use in Europe. It is also the most commonly used illicit drug, with nearly 20% of those in the 15-24 age group reporting to have used cannabis in the last year. Women are a significant minority of those with cannabis problems. </p>
<p>The potency of the cannabinoid substance depends on the balance between the two main cannabinoids, namely tetrahydrocannabinol (THC), responsible for the intoxicating effect and cannabidiol (CBD). CBD is increasingly marketed with claims about it&acute;s beneficial effects. Psychosis due to cannabis use is much more common compared to 50 years ago, when the fraction of THC was lower in the drug-forms in common use. Chronic effects include dependence, respiratory diseases and psychotic symptoms. Risks to health generally increase with early onset of use and are higher with increasing frequency of use and quantity used. It is important to note that hybrid multi-strain plants yielding higher-potency cannabis have begun to replace older established forms of the plant in Europe.  <br>
<br>
Studies show a slightly increased risk of preterm birth and low birth weight associated with frequent use of cannabis. Frequent high dose use might influence memory and executive functions in the offspring. As with all sedative drugs including cannabis and alcohol, it passes to breast milk. </p>
<h3>Stimulants and hallucinogens</h3>
<p>One might say that stimulants are associated with abuse, while hallucinogens are associated with recreation and not reported unless asked for specifically. </p>
<p>Cocaine is the most commonly used illicit stimulant drug. It decreases the urge to sleep and eat, acts on the pleasure centers in the brain and is highly addictive. </p>
<p>MDMA (3,4-methylenedioxy-methamphetamine) is used in the form of tablets (often called &ldquo;ecstasy&rdquo;), and also as crystals and powders; tablets are usually swallowed, but crystal and powder forms of MDMA may be taken orally or snorted. MDMA is often taken alongside other substances, including alcohol. Current indications suggest that, in higher-prevalence countries, MDMA is no longer a niche or subcultural drug limited to dance clubs and parties, but is used by a broad range of young people in mainstream nightlife settings, including bars and house parties.</p>
<p>Stimulant use causes vasoconstriction and reduced placental blood flow to the fetus.</p>
<p>Amphetamine abuse increases the risk of miscarriage, preterm birth, fetal death and growth restriction (smaller head circumference). Vasoconstriction causes poor blood flow to the placenta, increased risk of placental abruption and preterm premature rupture of the fetal membranes. A wide range of morphological changes in the fetus has been attributed to cocaine&rsquo;s vasoconstrictive effects, though the studies are small.</p>
<p>Documentation regarding the teratogenic effects of lysergide (LSD) is limited. Available data do not indicate that LSD is highly teratogenic.</p>
<p>When used near time of birth, withdrawal-like symptoms, with increased agitation or abnormal drowsiness, may occur in newborns. Long-term studies have documented reduced IQ and behavioral problems.</p>
<p>A mix of abuse with other illegal substances/drugs makes it difficult to separate the effects of different substances.</p>
<h3>Benzodiazepines (BDZ), benzodiazepine derivates and gamma-hydroxybutyric acid (GHB)</h3>
<p>There are rarely any medical indications for prescribing BDZ for more than 2-4 weeks. Even in low dosage they tend to cause &ldquo;inhibitory&rdquo; effects responsible for the characteristic effects of sedation, amnesia and motor incoordination. BDZs are probably the drugs that cause more disagreement between different health professionals and different users and also between these groups.</p>
<p>Generally the risk of birth defects is considered low when administered in therapeutic doses. However, the risk is dose-dependent, and dosages of diazepam above 30-40 mg daily or use over extended periods can cause an increased risk of birth defects, including a marginally increased risk of cleft lip-palate. Abrupt discontinuation can cause withdrawal symptoms in both mother and fetus. Use in the third trimester increases the risk of withdrawal symptoms in newborns (tremors, irritability, hypertonicity and diarrhea/vomiting). In the third trimester gradual dose reduction may be necessary to avoid withdrawal symptoms for both mother and fetus. If used continuously up to delivery, BDZ use has been associated with "floppy infant syndrome" with symptoms such as hypotension, hypothermia, breathing problems, lethargy and breastfeeding problems.<br>
<br>
GHB is difficult to classify because of a variable effect on different receptors. Illicit GHB is used for its euphoric and aphrodisiac-like effects, as well as for its enhancing effects on social behavior; it has become progressively popular as a party drug. It is also associated with abuse, frequent overdoses, coma and (severe) intoxications including hallucinations, delusions, rhabdomyolysis, seizures and delirium. Knowledge of its fetal effects is currently limited. </p>
<h3>Opioids</h3>
<p>Around 50 new synthetic opioids have been reported to the EU Early Warning System on new psychoactive substances.One in five persons entering treatment for an opioid-related problem reports a synthetic opioid such as buprenorphine or oxycodone, rather than heroin, as their main drug of abuse: These drugs are becoming more commonly detected in drug overdose cases. </p>
<p>Psychosocially assisted opioid maintenance treatment (OMT) is the first-line treatment for opioid dependence in pregnant women. The pharmacological interventions widely used are methadone, buprenorphine and slow-release oral morphine (SROM). The psychosocial interventions cover different cognitive behavioral approaches. Opioid substitution therapy reduces opioid use and injecting risk, improves physical and mental wellbeing, and reduces mortality. Several combinations of substitution medicines and psychosocial approaches are available.<br>
<br>
NAS is a group of problems that occur in a newborn exposed to addictive illegal or prescription drugs antenatally. NAS occurs independent of dosage and every fetus has its own vulnerability level for developing NAS. Withdrawal symptoms are tremors, trembling, respiratory problems, breastfeeding problems, yawning, sneezing, and possibly convulsions. These infants can have problems with hypersensitivity to sensory input, sound, light or touch for several months after birth. Children of mothers who use methadone have the most prolonged withdrawal symptoms. The only way to make sure that the newborn does not develop NAS is abstinence from drug use lasting for several weeks before the birth.<br>
The data regarding effects of opioid exposure during pregnancy on cognitive and psychomotor effects in children are conflicting. <br>
<br>
Some studies have indicated a clear negative effect of opioid exposure during pregnancy on psychomotor and cognitive skills, as well as other parameters as such as visual function, immunological status and overall child mortality. Other studies show some effects on long-term outcome, but results are still within the normal range, or without statistical significance.</p>
<p>&nbsp;</p>
<p><strong>Keywords:&nbsp;</strong>Alcohol, substance abuse (disorder), pregnancy, cannabis, opioids</p>
<h2>Multiple choice quiz</h2>
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