Pregnant women continue to use multiple prescription, over-the-counter & illegal substances at alarming rates during pregnancy. Substance abuse during pregnancy is an equal opportunity phenomenon--affecting women of all races, ages, cultures, and socioeconomic levels. Most times it's difficult to identify or "spot" the substance abusing pregnant woman since she doesn't fit the conventional stereotype. The substance abusing pregnant woman may very well be the homeless, disheveled, expressionless street person we associate with substance abuse, but she is just as likely to be the clean-cut, vivacious high school or college student or the housewife next door. She may be employed full- or part-time; and substance abuse is not limited to a single ethnic/racial group--Caucasians, Hispanics, and African Americans are all using and abusing substances.
The use of these substances--legal and illegal--places both the life of the woman as well as her unborn child at risk. Abused substances span a wide range from opiates, marijuana, cigarettes, cocaine, alcohol, hallucinogens, inhalants, tranquilizers, stimulants to sedatives. The growing abuse of phencyclidine (PCP), cocaine and cocaine's potent form "crack," added to the more well-known narcotics such as heroin, is worrisome. It is estimated that some 15% of women of child bearing age (15-44 years) are current substance abusers. Approximately 30 million women consume alcohol, 18 million are active cigarette smokers and more than 6 million women are current users of an illegal substance.....................and of these 6 million women, about ½ have tried marijuana and another ¼ have tried cocaine at least once. Of these women, some 2-10% will abuse a substance during their pregnancy.
Furthermore, few of the legal substances commonly prescribed for pregnant women have been evaluated prospectively in pregnant women prior to Federal Drug Administration (FDA) approval and distribution. Interestingly enough, Congress recently approved legislation allowing the FDA to mandate drug trials in children to assure access to safe and effective medicines and verification of appropriate pediatric dosages. This new legislation, which expires in 2007, allows the FDA to require testing for both new drugs awaiting approval as well as current drugs already on the market that are commonly prescribed for children. Unfortunately, prospective evaluation of illegal substances in any population (pregnant or not) is not likely to happen. As such, potential risks to the fetus & newborn are based on case studies and survey's of affected children, and animal studies. We do know, however, that exposure to certain substances during the pregnancy poses a major threat to the fetus and newborn. Exposure can result in a variety of structural, functional and/or developmental problems. Fetal, and ultimately infant, morbidity from prenatal substance exposure is tied to:
a. Direct effects of the substance on the developing fetus
b. Effects of sudden withdrawal of the substance
c. Interaction(s) of multiple abused substances
d. Maternal nutritional status
e. Maternal life style and health care.
The low molecular weight and lipophilic and water-soluble properties of many drugs facilitate their transfer across the placenta allowing accumulation of the drug in the fetus and the amniotic fluid. The half-life of most drugs is longer in the fetus than in the adult thus promoting their accumulation. Some drugs—cocaine for example—have a direct physiologic effect on the pregnancy and fetus potentially resulting in an increased incidence of premature labor, distress during labor, growth retardation, congenital anomalies, or neurobehavioral abnormalities to name a few. Alcohol—one of the most commonly abused legal substances—easily crosses the placenta exposing the fetus to both the alcohol itself as well as its metabolites, resulting in a wide range of effects in the infant. Still other drugs—in utero narcotic exposure for example—often cause a passive addiction resulting in characteristic withdrawal signs in the newborn referred to as neonatal abstinence syndrome (NAS) that may persist for 2 weeks or longer.
National surveys as well as the American Academy of Pediatrics (AAP) estimate as many as one in 10 infants born each year may have been exposed to illegal drugs in utero. While this initially may appear to be a small number, it actually translates to the exposure of and possible affliction of hundreds of thousands of infants annually; a recent estimate was > 220, 000 exposed infants. A number of these infants will experience post-natal complications as a result of this intrauterine exposure. Fortunately for many infants, the necessary parental, social supports and/or support services are identified and made available prior to the mother’s & infant’s discharge from the hospital. Sadly, infants who do not exhibit complications while still hospitalized may go unrecognized and be sent home without the necessary preparations. This lack of identification & mobilization of services may negatively influence the long-term health and well-being of both the infant and the family.
