Copyright 1997 The McGraw-Hill Companies, Inc.
Post Graduate Medicine
September, 1997


LENGTH: 5954 words

HEADLINE: Substance abuse in pregnancy

BYLINE: Jeffrey C. King, MD

A bigger problem than you think

    PREVIEW Many people think of crack and heroin addiction when they hear the words ''substance abuse,'' but legal substances, such as alcohol, tobacco, amphetamines, and benzodiazepines, can also be abused. When a pregnant women is the abuser, she is potentially damaging two persons. And, since abusers rarely abuse just one substance, the growing fetus may bear the negative impact of multiple substances. Dr King maintains that many pregnant women would try to reduce their substance use if they understood the potential outcome of their actions, and he calls for physicians to identify and counsel women who need help confronting their problem.
Many people consider substance abuse to be one of the major problems confronting modern obstetrics, as well as society as a whole. Few issues have caused more controversy and debate in both the medical and lay press than substance abuse -- defined as use of any psychoactive substance to such an extent that significant physical, emotional, and social consequences result. Potential deleterious effects on the developing fetus raise numerous medical, ethical, economic, and legal questions. Some states require that physicians report documented or suspected substance abuse, which threatens to interfere with both patient confidentiality and the physician-patient relationship. Therefore, it is crucial that obstetrician-gynecologists and other primary care providers be knowledgeable about the issues of substance abuse and alert for opportunities to prevent abuse, treat affected patients, and educate patients and families.
Patterns and variables among abusers
At one time, people believed that women who abused substances were unable to distinguish right from wrong, to feel and return love, or to concentrate and experience insight; in addition, people thought such women invariably bequeathed severe brain damage to their babies.1 ( Reference) Fortunately, these beliefs were based on individual opinion, isolated case reports, and research that lacked proper scientific controls. Since then, appropriately controlled studies have been conducted that reflect more accurate assessment of pregnancy outcomes in substance abusers.

Substance abuse is typified by great diversity of use patterns, repeated cycles of relapse and dependence, and wide variety in individual response to treatment and long-term prognosis. Unfortunately, abusers rarely abuse only a single substance. Those who abuse illicit substances often also abuse legal ones, such as tobacco, alcohol, or both.2 ( Reference) Therefore, the potential impact of multiple substances must be taken into account when attempting to evaluate the effects of substance abuse on the fetus.

Another confounding variable is the unknown effects of multiple diluents that are often added to drugs, either before they are purchased on the street or before they are taken. Therefore, it is probably more appropriate to use the encompassing term ''substance abuse'' than to refer to problems caused by an isolated drug, such as ''cocaine abuse'' or ''alcoholism.''
Scope of the problem
Establishing the true prevalence of substance abuse in pregnant women is difficult if not impossible for a number of reasons. First, illegal drug use often occurs against a backdrop of legal drug use (eg, cocaine and alcohol) . Second, obstetric complications attributed to drug use may be intensified by coexisting factors, such as a chaotic family environment and malnutrition. Third, despite the increased public appreciation of substance dependence as a medical disease, a social stigma continues to be attached to identified abusers, making many reluctant to admit their alcohol and drug use.

Vega and associates3 (Reference) tested urine samples of 29,494 women presenting for delivery in 202 California hospitals and found that 6.7% of samples were positive for alcohol and 5.2% were positive for one or more illicit substances. In its 1994 National Household Survey on Drug Abuse, the National Institute on Drug Abuse conducted face-to-face interviews and found that 9.4% of pregnant women had used an illicit drug during the past year.4 (Reference)

In Pinellas County, Florida, Chasnoff and associates5 (Reference) did a cross-sectional study of substance abuse by pregnant women by obtaining urine samples from all patients presenting for prenatal care in either a public- or private-care setting. About 15% of the women had toxicologic evidence of recent substance use. The investigators found no statistically significant difference in prevalence of recent use between medically indigent patients (16.3%) and privately insured patients (13.1%). In a statewide prevalence study in Rhode Island,6 (Reference) 7.5% of women admitted to the hospital in labor had toxicologic evidence of recent substance use.

Gomby and Shiono,7 (Reference) by assuming that drug consumption is the same in pregnant and nonpregnant women, concluded that between 15.8% and 21% (mean, 18.4%) of pregnant women use illicit drugs. This assumption may overestimate use, since some women abstain while pregnant. On the other hand, estimates that rely on conservative measures of drug use (eg, urine tests, self-reporting) may reveal just the tip of the iceberg.8 (Reference) In urban populations receiving care at large medical centers, routine urine testing at the time of labor has demonstrated rates of illicit substance abuse of 20% or higher.9 (Reference)

A statewide study in South Carolina10 (Reference) found that the combination of newborn meconium and maternal urine tests detected more than twice as many drug users (23.9%) as maternal urine tests alone (10.2%). These data support the belief that urine screening has poor sensitivity for substance use except when use is relatively recent. Until meconium and other more sensitive tests are widely employed, substance use by pregnant women will probably continue to be one of the most frequently missed diagnoses in obstetric and pediatric medicine.

Nicotine and alcohol are the substances most widely used during pregnancy. Of the more than 4 million women who become pregnant each year, at least 800,000 (20%) smoke cigarettes and 757,000 (18.8%) drink alcohol during their pregnancy.11 (Reference)

On the basis of the studies mentioned, it appears that at least 20% of pregnant women expose their unborn child to legal substances and at least 10% to illicit ones. Those who continue to use drugs often do so to avoid withdrawal symptoms, to obtain even temporary relief from oppressive living situations, or simply to get high. Unfortunately, many women continue to use drugs without realizing the dangers involved for themselves and their babies.
Detection through communication and screening
Patients should be given the opportunity to confront their substance abuse. Often, patients reveal their dependence only when they perceive an accepting attitude from their healthcare provider. Direct questioning is the recommended approach, but most physicians do not routinely screen for substance abuse. Surveys suggest that only 40% of physicians ask about alcohol use and only 20% about other drug use. Although denial remains a hallmark of both alcoholism and drug dependence, physicians may open lines of communication by establishing a trusting relationship. Pregnancy may motivate some addicted women to stop using both legal and illicit substances, at least temporarily; however, many are unable to stop on their own. Therefore, identifying substance abusers is paramount. Until a patient realizes she has a problem, there can be no intervention and no cure.
Screening questionnaires In general, patients tend to minimize substance abuse, often giving inaccurate information about quantity and frequency of consumption. Alcoholics may underreport the amount consumed but be more accurate regarding the frequency of use. To disclose the best quantitative data, physicians should ask direct questions, such as, ''Has your level of drinking changed during your pregnancy?'' or ''What did you drink yesterday?''

Several screening questionnaires have been developed to help detect problem drinking. The most widely known is the four-item CAGE questionnaire,12 (Reference) which has 91% sensitivity and 77% specificity. The T-ACE questionnaire13 (Reference) is a modification for alcoholism screening in obstetric patients. Unfortunately, few screening tools are available for evaluating illicit drug use in pregnant women, and the accuracy of those that exist has not been extensively validated. In an attempt to fill this void, the modified CAGE questionnaire was developed14 (Reference); it has been shown to be in overall agreement with other indicators of drug use. These questionnaires are shown in the box on page 140.
Toxicology tests Funkhouser and colleagues15 (Reference) reported that in a high-risk population of pregnant women, urine toxicology screening identified substance abuse more often than did history taking. Therefore, toxicologic testing should be considered an integral part of the identification process. However, because of its cost and sensitivity to only relatively recent drug use, urine toxicologic screening should not be done routinely. Rather, it should be reserved for specific situations.

Toxicology screening with informed consent is recommended in pregnant women with self-reported substance abuse to assess compliance with treatment and in women with multiple behavioral characteristics suggestive of drug abuse to facilitate referral to a comprehensive-care program. Most laboratories perform a standard drug panel aimed at the most commonly used local drugs (eg, marijuana, cocaine, amphetamines, barbiturates, opiates, and alcohol) , so less commonly used drugs (eg, LSD) would not be detected. Table 1 shows the interval of time after use when various drugs may be detected in urine. Attempts to dilute or '' wash out'' a substance by consuming large quantities of water before testing are usually unsuccessful because of increased sensitivity of modern testing within the time frames identified. In addition, meconium or hair of the newborn represents a reservoir for possible substance use over a longer duration, so these analyses are probably better in identifying earlier substance use.

Although urine is the preferred specimen for testing because it is readily available, other maternal or fetal biologic substances, including amniotic fluid, blood, meconium, and hair, may be evaluted. Meconium may be the ideal substance because drugs are detectable for a prolonged time interval.

The initial screening test in the laboratory is usually an immunoassay procedure, but confirmatory testing with gas chromatography or mass spectrometry is advised to reduce the incidence of false-positive results.
Complications of specific substances
Substance abusers often have additional problems that complicate pregnancy, such as sexually transmitted disease, late or inadequate prenatal care, and poor nutrition. Unfortunately, most studies of the impact of substance abuse during pregnancy have been done in urban, poor, minority populations, which are already at increased risk for adverse outcomes. In spite of these shortcomings, studies have found that certain complications accompany use of certain substances.
Alcohol The adverse effects of alcohol consumption have been recognized for centuries, but the associated pattern of fetal anomalies was not described until 1968. However, it was not until 1973 that Jones and associates16 ( Reference) called the pattern '' fetal alcohol syndrome' ' and identified three specific findings: growth retardation (prenatal, postnatal, or both), craniofacial dysmorphism, and central nervous system dysfunction. The cardiac and genitourinary systems may also be affected.

Exact risks of certain degrees of maternal alcohol use are difficult to establish. Patients should be counseled that there is no safe level of alcohol use during pregnancy. In the United States, fetal alcohol syndrome, which is recognized in 1 per 500 to 1,000 deliveries, is the most commonly identified cause of mental retardation.17 (Reference) Since some features are not obvious at birth, the syndrome may affect as many as 30 per 10,000 births, or about 12,000 babies each year. Consumption of 1 to 2 oz of absolute alcohol (two to four drinks) per day carries about a 10% chance of resulting in at least some characteristics of fetal alcohol syndrome in offspring.18 (Reference) Even among chronic alcoholics, the incidence of the syndrome in offspring is highly variable, ranging from as low as 6% to as high as 50%.19 (Reference)

Fetal alcohol effects, a condition manifesting only central nervous system abnormalities, may affect triple the number of children identified with obvious fetal alcohol syndrome. 20 (Reference)

Alcohol consumption during pregnancy has been associated with an increased risk of second-trimester abortion and a 50% increase in infant mortality. In infants born to continuing alcoholics, withdrawal may occur within the first 12 hours of life; short-term barbiturate therapy is occasionally necessary to control symptoms.

The long-term effects of fetal alcohol syndrome depend on the severity of malformations and central nervous system dysfunction.
Cocaine It is estimated that at least 10 million Americans have used cocaine and at least 5 million are regular users. In some inner-city hospitals, 15% of women presenting for delivery have evidence of recent cocaine use.21 (Reference) Cocaine is rapidly absorbed by all mucous membranes. Its effects are due to blockade of reuptake of both norepinephrine and dopamine. Euphoria is the central manifestation of this blockade, and vasoconstriction, tachycardia, and local anesthesia are peripheral effects. Both plasma and liver esterases metabolize cocaine. Since cholinesterases are immature in the fetus, cocaine metabolites may be concentrated to some extent within the fetal compartment.

Crack is an easily manufactured form of cocaine whose effects are not destroyed by heat, so high blood levels can be rapidly achieved by smoking it. The resulting euphoria increases desire, escalates use, and quickly leads to addiction. Even though crack is relatively inexpensive, numerous studies have shown that addicted women often trade sex for drugs, which increases the risk of HIV infection and other sexually transmitted diseases.

With the widespread use of crack came a flood of reports in the lay press in the mid-1980s of birth complications and developmental problems. Despite this concern over the fate of ''crack babies,'' few early studies considered that many of them were also exposed to alcohol, tobacco, benzodiazepines, marijuana, or other drugs and were born to malnourished mothers who had received little or no prenatal care. Subsequent studies have confirmed that cocaine use may cause serious damage but also that many infants are surprisingly resilient and may overcome initial signs of physical or cognitive impairment.

Maternal complications from cocaine use include malignant hypertension, cardiac ischemia, cerebral infarction, and even sudden death. Effects on the fetus may include spontaneous abortion and death in utero.22 (Reference) In addition, pregnant cocaine users are at high risk for premature rupture of membranes (20%), preterm labor and delivery (25%), intrauterine growth restriction (25% to 30%), meconium-stained amniotic fluid (29%), and abruptio placentae ( 6% to 8%).23 (Reference)

One study found that in babies born to cocaine users, the average birth weight was reduced 154 g; when other illicit drugs were used as well, the average reduction was 195 g.24 (Reference) Although cocaine has not been identified as a true teratogen, several studies have noted an increased frequency of fetal microcephaly. Limb reduction defects and genitourinary malformations have also been reported in babies born to cocaine users. Vascular interruption from the intense vasoconstriction accompanying cocaine use may be the cause of these malformations.

Newborns of cocaine-addicted women may display symptoms that mimic withdrawal, such as tremulousness, irritability, and inability to suck properly. However, they do not require medication; rather, they need a peaceful environment and the calming and tenderness provided by swaddling and rocking.25 (Reference) In addition, cocaine use in the mother has been linked to some cases of cognitive and neurobehavioral problems, lack of coordination, overstimulation, and difficulty in tracking visual stimuli in offspring.
Marijuana Marijuana comes from the plant Cannabis sativa; its active ingredient is delta-9-tetrahydrocannabinol. In a 1980 study,26 (Reference) the estimated incidence of marijuana use during pregnancy varied between 3% and 15%. The effects on fetal development and obstetric outcome are unclear, but there is no scientific evidence that marijuana is a significant teratogen.

Because of their high lipid solubility, cannabinoid metabolites can be detected in the urine of even occasional users for days to weeks after discontinuation of use -- significantly longer than can other illicit substances or alcohol. 27 (Reference) Since abusers of multiple substances often use marijuana, a positive urine test for cannabinoids may identify patients at high risk for other substances.
Tobacco As recently admitted by a US tobacco company, tobacco is addicting. Therefore, no discussion of substance abuse is complete without addressing the issues associated with tobacco. Overall, 25% to 30% of women of reproductive age smoke. Although the incidence of smoking declined in both men and women between 1965 and 1994, the rate of decline in women (35%) is less than in men (46%). If this trend continues, by the year 2000 more women than men will be smokers, giving an entirely new meaning to the advertising slogan, ''You've come a long way, baby.''

Fortunately, there has been a decline in smoking among adolescents between ages 12 and 17. From 1985 through 1992, those who admitted smoking within the past month declined progressively, from 30% to 17.5%. Unfortunately, since 1992, those in same age category who reported smoking within the past month increased to 21% -- almost a 4% rise.

More than 140,000 women die each year of illness directly related to smoking. In 1986, more women died of lung cancer than breast cancer.28 (Reference) Women who use alcohol or illicit drugs are far more likely than abstainers to use tobacco as well, which underscores the problem of multidrug exposure for the fetus.

Several obstetric complications occur more often among smokers. Smoking during pregnancy results in up to 141,000 spontaneous abortions, 61,000 deliveries of low-birth-weight infants, and 4,800 perinatal deaths each year.29 (Reference) Premature rupture of membranes and preterm delivery are proven complications of smoking,30 (Reference) and newborns of heavy smokers weigh a mean of 200 g less than those of nonsmokers.31 (Reference) In addition, 1,200 to 2,200 cases of sudden infant death syndrome a year and a significant number of chronic respiratory illnesses in children (eg, asthma, otitis media) are related to maternal smoking.32 (Reference)

Quitting or reducing smoking during pregnancy can result in improved birth weight and reduced risk of prematurity. A study at maternity clinics33 (Reference) showed that after controlling for the mother's age, race, and height and the gestational age at delivery, infants born to mothers who quit smoking averaged 241 g heavier and those born to mothers who reduced their smoking level averaged 92 g heavier than infants born to mothers who did not change their smoking habit. Quitting altogether lengthened pregnancy 1 week, reducing the chance of complications related to premature birth. Although quitting before 16 weeks of gestation ameliorates many adverse effects, quitting as late as the third trimester can also have a positive impact, since so much fetal growth occurs during this time.34 (Reference)
Opiates Originally, the term ''opiates'' referred only to drugs derived from opium, but it has come to be used as a general term for natural, semisynthetic, and synthetic drugs of this type. Morphine and codeine are derived from opium. Heroin, oxymorphone hydrochloride (Numorphan), and hydromorphone hydrochloride (Dilaudid) are semisynthetic drugs derived from ingredients of opium. Meperidine hydrochloride (Demerol), methadone hydrochloride (Dolophine), and fentanyl (Sublimaze) are purely synthetic creations. The term ''designer drugs'' refers to analogues of meperidine and fentanyl.

There is no question that narcotic addition during pregnancy poses serious health risks to the mother and the fetus. Cellulitis, abscess formation, endocarditis, hepatitis, and HIV infection are seen with increasing frequency among opiate users owing to the practice of sharing needles. In New York City and Newark, New Jersey, the prevalence of HIV antibody in injecting drug users is greater the 50%.35 (Reference) The rates of stillbirth, fetal growth restriction, prematurity, and neonatal mortality are three to seven times higher in heroin addicts than in the general population.36 (Reference) Whether these outcomes are the result of drug abuse or of the multiple concurrent health and social problems is difficult to determine.

In general, abrupt cessation of opiates in gravid women is not advised, because intrauterine fetal death or distress may result. Patients enrolled in a methadone maintenance program often have a good outcome, including longer gestation time and increased birth weight, compared with untreated opiate abusers.37 (Reference) However, even with adherence to a methadone maintenance program, mothers using opiates deliver infants with low birth weight and small head circumference.

Narcotic withdrawal syndrome occurs in about 30% to 90% of infants exposed to heroin or methadone in utero.38 (Reference) The severity of withdrawal is slightly less in infants of methadone-treated mothers but it can be just as serious. Neonatal signs include a high-pitched cry, poor feeding, hypertonicity, tremors, irritability, sneezing, sweating, vomiting, diarrhea and, occasionally, seizures. In heroin-addicted mothers, signs in the infant may appear within 24 to 72 hours after birth. In mothers maintained on methadone, signs in infants may be delayed an additional 1 or 2 days. On occasion, in offspring of methadone-treated mothers, signs do not appear for up to 10 days, so mothers must be instructed to watch for withdrawal features in the infant.

In an analysis of opiate addiction and its confounding variables, Chasnoff39 (Reference) failed to demonstrate long-term developmental impact from in utero exposure.
Amphetamines Illicit amphetamine use during pregnancy has received relatively little scientific study because of its infrequency compared with cocaine and narcotic use. The spectrum of fetal effects from amphetamines is similar to the effects of cocaine, suggesting vasoconstriction as a mechanism. Because of their anorectic impact, amphetamines may severely affect maternal nutrition during pregnancy, leading to problems with fetal growth and birth weight and possibly neural tube malformation. Use of crystal methamphetamine (''ice'' or ''blue ice'') by gravid women has been associated with reduced fetal head circumference, increased risk of abruptio placentae, intrauterine growth restriction, and fetal death in utero.40 (Reference)
Intervention and support
Intervention can reduce substance use and improve pregnancy outcome. Fortunately, most women who are using during pregnancy are not addicted; they may have become emotionally dependent on a substance but do not have withdrawal symptoms when it is removed. Education is the most appropriate first step in intervention. Studies have consistently shown that messages from physicians have more impact than messages from nonphysicians.41 (Reference) Many pregnant substance users would probably stop or at least cut down if they knew about the consequences of their actions.

Face-to-face discussions regarding the hazards of substance use during pregnancy are more effective than handouts. Discussions need to be reinforced at each prenatal visit to determine patients' responses to information they have received. Inquiries about substance use since the last visit open the door for more discussion and education. When physicians are open and nonjudgmental, patients are likely to provide honest responses. Abstinence or even small reductions in intake should be supported and rewarded. Patients who are unable to take the first step should be referred to a qualified treatment center for additional evaluation of drug dependence.

Employees at every healthcare facility should know about local resources for drug-abuse assessment. Services may range from intensive residential care to individual or group counseling. Women have been shown to require and benefit from focused treatment, so these services within a community should be identified. Some communities even have specialized services for pregnant women, such as child care, transportation, housing advice, and job training.

Even though the door has been opened, patients may be reluctant to accept referral to a treatment center. Denial must be overcome repeatedly. The physician should stress that he or she will be working with the team of healthcare professionals to optimize the patient's therapy, recovery, and pregnancy outcome. Maintaining regular contact with the team involved reinforces to the patient the physician's commitment to her and her infant.
The public and even physicians have been led to believe that substance abuse occurs only in lower socioeconomic groups. Nothing could be further from the truth. Substance abuse takes place among people of all colors, sizes, shapes, incomes, types, and conditions. Most pregnant women are unaware of the adverse effects their substance abuse can have on the baby. Additionally, they may fear that the baby and possibly other children will be taken from them if their problem is discovered.

It is the responsibility of physicians to identify, educate, counsel and, as necessary, refer pregnant women with substance-abuse problems. We can make a difference if all doctors and ancillary healthcare personnel are willing to make a ''contract'' with our patients to help them toward a drug-free pregnancy, baby, and life.42 (Reference)
1. Zuckerman B, Frank DA. ''Crack kids'': not broken. Pediatrics 1992;89(2):337-9
2. Little BB, Snell LM, Klein VR, et al. Cocaine abuse during pregnancy: maternal and fetal implications. Obstet Gynecol 1989;73(2):157-60
3. Vega WA, Kolody B, Hwang J, et al. Prevalence and magnitude of perinatal substance exposures in California. N Engl J Med 1993; 329(12):850-4
4. Gfroerer JC. National Household Survey on Drug Abuse: population estimates 1994. Rockville, Md: Office of Applied Studies, 1995; DHHS publication No. 95-3063
5. Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicit- drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N Engl J Med 1990;322(17):1202-6
6. Centers for Disease Control. Statewide prevalence of illicit drug use by pregnant women: Rhode Island. MMWR 1990;39(14):225-7 [Erratum, MMWR 1990;39(16):280]
7. Gomby DS, Shiono PH. Estimating the number of substance-exposed infants. Future Children 1991;1(1):17-25
8. Chasnoff IJ. Cocaine, pregnancy, and the growing child. Curr Probl Pediatr 1992;22(7):302-21
9. Gillogley KM, Evans AT, Hansen RL, et al. The perinatal impact of cocaine, amphetamine, and opiate use detected by universal intrapartum screening. Am J Obstet Gynecol 1990;163(5 Pt 1):1535-42
10. Chasnoff IJ. Drug use and women: establishing a standard of care. Ann N Y Acad Sci 1989;562:208-10
11. US Department of Health and Human Services. National pregnancy & health survey: drug use among women delivering livebirths, 1992. Rockville, Md: Dept of Health and Human Services, 1996; NIH publication No. 96-3819
12. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252(14):1905-7
13. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol 1989;160(4):863-8
14. Svkis DS, Gupman AE, McCaul ME. Prevalence and detection of drug and alcohol use in a gynecologic clinic. Presented at the annual meeting of the American Public Health Association. Washington, DC: 1994 Nov
15. Funkhouser AW, Butz AM, Feng TI, et al. Prenatal care and drug use in pregnant women. Drug Alcohol Depend 1993;33(1): 1-9
16. Jones KL, Smith DW, Ulleland CN, et al. Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1973;1(815):1267-71
17. Abel EL, Sokol RJ. Fetal alcohol syndrome is now leading cause of mental retardation. (Letter) Lancet 1986;2(8517):1222
18. Hanson JW, Streissguth AP, Smith DW. The effects of moderate alcohol consumption during pregnancy on fetal growth and morphogenesis. J Pediatr 1978;92(3):457-60
19. Olegrd R, Sabel KG, Aronsson M, et al. Effects on the child of alcohol abuse during pregnancy: retrospective and prospective studies. Acta Paediatr Scand (Suppl) 1979;275:112-21
20. Caruso K, ten Bensel R. Fetal alcohol syndrome and fetal alcohol effects: the University of Minnesota experience. Minn Med 1993;76(4):25-9
21. Spence MR, Williams R, DiGregorio GJ, et al. The relationship between recent cocaine use and pregnancy outcome. Obstet Gynecol 1991;78(3 Pt 1):326-9
22. Chasnoff IJ, Burns WJ, Schnoll SH, et al. Cocaine use in pregnancy. N Engl J Med 1985;313(11):666-9
23. MacGregor SN, Keith LG, Chasnoff IJ, et al. Cocaine use during pregnancy: adverse perinatal outcome. Am J Obstet Gynecol 1987;157(3):686-90
24. Bateman DA, Ng SK, Hansen CA, et al. The effects of intrauterine cocaine exposure in newborns. Am J Public Health 1993;83(2):190- 3
25. Chasnoff IJ. Newborn infants with drug withdrawal symptoms. Pediatr Rev 1988;9(9):273-7
26. Fried PA. Marijuana use by pregnant women: neurobehavioral effects in neonates. Drug Alcohol Depend 1980;6(6):415- 24
27. American College of Obstetricians and Gynecologists. Substance abuse in pregnancy. Washington, DC: ACOG, 1994; ACOG Technical Bulletin No. 195
28. US Department of Health and Human Services. Vital Statistics of the United States, 1986, vol 2, mortality. Hyattsville, Md: National Center for Health Statistics, 1988
29. National Center on Addiction and Substance Abuse. Substance abuse and the American woman. New York: Columbia University, 1996:77
30. Naeye RL. Factors that predispose to premature rupture of the fetal membranes. Obstet Gynecol 1982;60( 1):93-8
31. American College of Obstetricians and Gynecologists. Smoking and reproductive health. Washington, DC: ACOG, 1993; ACOG Technical Bulletin No. 180
32. DiFranza JR, Lew RA. Effect of maternal cigarette smoking on pregnancy complications and sudden infant death syndrome. J Fam Pract 1995;40(4):385-94
33. Li CQ, Windsor RA, Perkins L, et al. The impact on infant birth weight and gestational age of cotinine-validated smoking reduction during pregnancy. JAMA 1993;269(12): 1519-24
34. MacArthur C, Knox EG. Smoking in pregnancy: effects of stopping at different stages. Br J Obstet Gynaecol 1988;95(6):551-5
35. Hahn RA, Onorato IM, Jones TS, et al. Prevalence of HIV infection among intravenous drug users in the United States. JAMA 1989;261(18):2677-84
36. Fricker HS, Segal S. Narcotic addiction, pregnancy, and the newborn. Am J Dis Child 1978;132(4):360-6
37. Newman RG, Bashkow S, Calko D. Results of 313 consecutive live births of infants delivered to patients in the New York City Methadone Maintenance Treatment Program. Am J Obstet Gynecol 1975;121(2):233-7
38. Ostrea EM, Chavez CJ, Strauss ME. A study of factors that influence the severity of neonatal narcotic withdrawal. J Pediatr 1976;88(4 Pt 1):642-5
39. Chasnoff IJ. Effects of maternal narcotic vs nonnarcotic addiction on neonatal neurobehavior and infant development. In: Pinkert TM, ed. Consequences of maternal drug abuse. Rockville, Md: Dept of Health and Human Services, 1985:84-95; DHHS publication No. (ADM)85-1400
40. Oro AS, Dixon SD. Perinatal cocaine and methamphetamine exposure: maternal and neonatal correlates. J Pediatr 1987;111(4):571- 8
41. Walsh DC, Hingson RW, Merrigan DM, et al. The impact of a physician's warning on recovery after alcoholism treatment. JAMA 1992;267(5):663-7
42. Little RE. Alcohol consumption during pregnancy as reported to the obstetrician and to an independent interviewer. Ann N Y Acad Sci 1976;273:588-92
Table 1. Interval after use within which various drugs can be detected in urine 
Drug                 Interval 
Alcohol              24 hr 
Amphetamines         48 hr 
  Short-acting       48 hr 
  Long-acting        7 days 
Benzodiazepines      72 hr 
Cocaine              72 hr 
  Single use         72 hr 
  Chronic use        30 days 
  Morphine, heroin   48 hr 
  Methadone          96 hr 

Questionnaires for detection of substance abuse 
CAGE (for problem drinking) 
C                    Have you ever felt you ought to cut down on your drinking? 
A                    Have people annoyed you by criticizing your drinking? 
G                    Have you ever felt guilty or bad about your drinking? 
E                    Have you ever had an eye opener first thing in the morning 
                    response to steady your nerves or get rid of a hangover? 
1 point for each yes 
A score of 2 or 3 is a strong indicator and 4 confirms alcoholism. 
Adapted from Ewing.12 (Reference) 
T-ACE (for problem drinking in obstetric patients) 
T                    What is your tolerance (the number of drinks it takes to 
                    make 2 points for greater than 2 drinks you feel high)? 
A                    Have you ever felt annoyed by someone criticizing your 
C                    Have you ever felt a need to cut down on your drinking? 
E                    Have you ever felt the need for an eye opener (a drink 
                    first thing in the morning)? 
1 point for each yes response 
A score of 2 or more indicates problem drinking. 
Adapted from Sokol et al.13 (Reference) 
Modified CAGE (for use of illicit drugs in obstetric patients) 
C                    Have you ever felt the need to cut down on your drug use? 
A                    Have you ever felt annoyed by someone criticizing your 
                    drug use? 
G                    Have you ever felt guilty about your drug use?               E                    Have you ever felt the need for an eye opener to avoid 
                    withdrawal symptoms or to recover from the effects of 
                    the previous night's drug use? 
1 point for each yes response 
A score of 1 indicates reason for concern; 2 indicates probable abuse. 
Adapted from Svkis et al.14 (Reference) 


GRAPHIC: Table, Photograph: Jeffrey C. King, MD Dr King is professor and vice chairman, department of obstetrics and gynecology, and director, division of maternal- fetal medicine, Wright State University School of Medicine, and medical director, Born Free Program, Miami Valley Hospital, Dayton, Ohio.

Correspondence: Jeffrey C. King, MD, Department of Obstetrics and Gynecology, Wright State University School of Medicine, 128 E Apple St, Suite 3800 CHE, Dayton, OH 45409-2793.


LOAD-DATE: September 25, 1997

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