Risks of Substance Use During Pregnancy
Substance use during pregnancy poses serious risks to both maternal and fetal health, significantly increasing maternal mortality, morbidity, and reducing quality of life for both mother and child. 1
Maternal Risks
Mortality and Morbidity
- Pregnancy-associated mortality involving opioids doubled from 4% to 10% of all maternal deaths between 2007 and 2016 1
- Substance use disorders contribute substantially to pregnancy-related deaths in multiple states 1
- Women are at particularly high risk of overdose and death in the first year after delivery 1
Infection Risks
- Intravenous opioid use increases risk of:
- HIV infection
- Hepatitis C
- Cellulitis
- Bacterial endocarditis
- Sepsis 1
Cardiovascular Complications
- Cocaine and methamphetamine use increases risk of:
- Severe hypertension
- Cardiovascular complications 1
Mental Health Impacts
- Substance use disorders often coexist with mental health conditions
- Untreated psychiatric illness may result in:
- Poor adherence to prenatal care
- Inadequate nutrition
- Exacerbation of underlying mental illness 1
- Maternal self-harm (suicide, injury, overdose) is a leading cause of maternal mortality 1
Fetal and Neonatal Risks
Tobacco Use Effects
- Placenta previa
- Placental abruption
- Fetal growth restriction
- Preterm premature rupture of membranes
- Ectopic pregnancy 1
Opioid Exposure
- Neonatal opioid withdrawal syndrome (NOWS)
- 24% of infants born to mothers on methadone or buprenorphine require medication for withdrawal 2
- Mean time until medication for withdrawal is required: 3.47 days 2
Hepatitis Transmission
- Hepatitis C virus (HCV) increases risk of:
- Fetal growth restriction
- Low birth weight
- Vertical transmission to infant 1
- Hepatitis B virus (HBV) can be transmitted perinatally, leading to chronic HBV infection 1
Barriers to Care and Treatment
Disclosure Challenges
- 54% of women do not disclose using at least one illicit drug for which they or their newborn test positive 3
- Women who don't disclose substance use are less likely to receive complete prenatal care 3
- Fear of legal consequences and child custody issues prevents many women from seeking care 1
Stigma and Legal Issues
- Many states consider substance use by pregnant women a criminal offense 1
- Social stigma drives many pregnant women away from needed care 1
- Providers must understand local laws regarding mandatory reporting requirements 1
Screening and Treatment Approach
Universal Screening
- All pregnant women should be screened for substance use regardless of demographics
- No correlation exists between maternal characteristics and disclosure of substance use 3
- Recommended screening tools:
- NIDA Quick Screen
- 4Ps
- CRAFFT 1
Treatment Recommendations
- For opioid use disorder, medication-assisted treatment (MAT) is recommended during pregnancy 1
- Maintain a non-judgmental approach when discussing substance use 1
- Avoid terms like "addict" when discussing substance use disorders 1
- Provide information about effects of substance use on mother and fetus 1
Postpartum Support
- Continue or initiate MAT after delivery for women with opioid use disorder 1
- Advocate against separation of women and their infants based solely on substance use disorder 1
- Provide contraception counseling within a reproductive justice framework 1
Important Caveats
- Substance use screening should be universal, as demographic factors do not predict substance use 3
- Women with no antenatal care have poorer outcomes overall 2
- A multidisciplinary approach involving obstetric providers, pharmacotherapy providers, behavioral health services, and social services is essential 1
- Providers must create a destigmatized healthcare environment to encourage disclosure and treatment engagement 3