Legal
Disinhibition may lead to aggression or risk-taking behaviour, toxicity, loss of consciousness and death
Long-term liver, brain, heart, stomach damage and obesity
Class B*
Buds
Synthetic
Oil
Sleepiness and heightened sensations
Long-term apathy, poor memory and rarely psychosis
Class A*
Intoxication followed by drowsiness, cardiac and respiratory depression
Long-term addiction, intense craving and withdrawal.
Injected
Class A*
Tablets
Intoxication
Intoxication
Sublingual
Can be injected
Class B*
Legal (lower doses)
Intoxication
Class C*
Can be injected
crack cocaine
Class A*
Rocks
Increases heart rate, respiratory rate, blood pressure, dilates pupils, euphoria, energy and confidence, anxiety, paranoia
Long-term depression, lethargy, lack of sleep, eating disorders
Swallowed (tablets or powder)
Smoked (crystals)
IV (powder)
Class B*
Tablets
Crystals
Increases heart rate, respiratory rate, blood pressure, dilates pupils, increases feelings of energy and confidence, anxiety, paranoia
Long-term depression, lethargy, lack of sleep, eating disorders
Swallowed (tablets or powder)
Smoked (crystals)
IV (powder)
Class C*
Powder Tablets
Long-term bladder problems, cognitive impairment
Swallowed (tablets)
Injected (liquid)
Class A*
Powder
Smoked or snorted (crushed tablets or powder)
Legal
Long-term damage to brain, muscle, liver, kidneys
Hallucinogenic at high doses
Injected (crushed tablets usually)
* The Misuse of Drugs Act 1971 sets out three categories, class A, class B and class C. Class A drugs are those deemed most dangerous, and carry the harshest punishments. Class C represents those deemed to have the least capacity for harm, which carry more lenient punishment. This classification is contentious because in reality the potential harm has little bearing on the class.
Effects of substances of misuse on pregnancy
Many women who drink alcohol to excess and use illicit drugs also struggle with mental health problems and other comorbid behaviours such as smoking, poor nutrition, complex social factors and poor attendance for antenatal care, which can all contribute to poor pregnancy outcome. It is therefore impossible to evaluate the risks of specific drugs to mother and baby in isolation. However, below is an attempt to do so.
Alcohol
Alcohol is teratogenic and fetotoxic with a dose-dependent effect. It can affect the entire reproductive process, the most vulnerable time for the fetus being before 10 weeks gestation. The level and pattern of consumption is important, with binge drinking being more harmful than daily drinking with the same weekly unit consumption. Controversy exists over whether infrequent low levels of alcohol consumption cause harm.
Cannabis
Cannabis is usually a mild intoxicant, but 1 in 10 users may experience confusion, hallucinations, anxiety and paranoia. The fat-soluble active ingredients can build up in the brain with regular use, causing apathy, poor concentration, poor short-term memory and sometimes psychosis. Data on the effects in pregnancy are poor and difficult to separate from those caused by tobacco, with which it is usually smoked.
Associated problems
associated with tobacco use (preterm delivery, FGR, NAS, sudden infant death syndrome)
mild NAS (36 hours)
neurodevelopmental disorders
poor parenting
Heroin
There are no specific effects of heroin on pregnancy, but its short half-life (6 hours) causes repeated withdrawal, which can lead to miscarriage.
Associated problems
first-trimester miscarriage
stillbirth
preterm delivery
NAS (24–36 hours)
Methadone
The long half-life of methadone (72 hours) reduces withdrawal symptoms and delays NAS (36–72 hours).
Buprenorphine
The long half-life of buprenorphine (37 hours) reduces withdrawal symptoms and delays NAS.
Codeine
Codeine is thought to be safe during pregnancy, although there is little evidence regarding misuse. Its short half-life may predispose to withdrawal and problems similar to heroin as well as NAS (24–36 hours).
Benzodiazepines
There is little conclusive evidence of direct harm to the pregnancy or the fetus, but most studies are on low doses. There is an association with cleft palate.
Associated problems
cleft palate
NAS (7–10 days, can be severe and prolonged)
concerns regarding brain development and FGR
Cocaine/crack cocaine, amphetamines and mephedrone
These stimulant drugs are quickly absorbed, inhibiting dopamine and serotonin reuptake in the brain, causing euphoria. The excess neurotransmitters then cause sympathetic nervous system stimulation: tachycardia, hypertension and vasoconstriction. Pregnancy harm is thought to arise from the consequences of vasoconstriction on the placenta, uterus and fetus.
Ketamine
Ketamine is a general anaesthetic that produces muscle relaxation and reduced pain sensation. It also stimulates the sympathetic peripheral nervous system, causing tachycardia, hypertension, bronchodilation and diarrhoea. There is little known about its effects on pregnancy, but it may be associated with hypotonia in the newborn.
Ecstasy
Ecstasy is an indirect monoaminergic agonist and serotonin reuptake inhibitor. There is little known about its effects on pregnancy, but it may be associated with delayed motor development in infancy.
Solvents
There is little known about their effects on pregnancy, but they may be associated with preterm delivery and congenital abnormalities.
‘Legal’ highs
These are drugs that produce similar effects to illegal drugs (central nervous system stimulation, depression or hallucination) but are not illegal. There is little information about the medical consequences of taking these drugs. It is likely, however, that those producing stimulant effects may cause problems during pregnancy similar to other stimulant drugs.
General principles of management
Philosophy of care
The general principles of managing substance misuse across the UK have been summarized in a Department of Health monograph, and the same principles apply during pregnancy.3 The care philosophy that should pertain especially during pregnancy has also been detailed in several guidance documents produced by the National Collaborating Centre for Women’s and Children’s Health and the National Institute for Health and Care Excellence (NICE).4 These are briefly outlined as follows:
Encourage the woman to attend regularly for antenatal care.
Encourage the woman and her partner to engage in treatment for their substance misuse.
Normalize maternity care as much as possible, while recognizing the social and medical problems associated with substance misuse.
Provide accurate and honest advice regarding the risks of substance misuse to the woman and her baby.
Ensure that regular communication exists between all professionals, so that advice is consistent, and that any concerns are dealt with appropriately.
Provide an individualized multi-agency care plan consistent with minimizing harm and stabilizing lifestyle.
Following birth, promote bonding and facilitate good parenting skills.
Provide family planning and sexual health advice.
Attitude
There is a prevailing misconception in society that women who misuse substances are less deserving of medical and social care than those who do not, and that they make unfit mothers. This attitude, with its concomitant fear of judgement and having a child removed, can lead to the non-disclosure of substance misuse and is the single most important barrier to effective and safe care for this group of women. It is therefore imperative for healthcare professionals to adopt an attitude which projects an understanding that substance misuse is a chronic disease of a relapsing and remitting nature that is not the ‘fault’ of the patient. Substance misuse and parenting are not mutually exclusive, and the best place of care for the majority of children is with their mother.
Holistic care
Women who misuse substances often have comorbid medical conditions whose management is compromised by their substance misuse. Pregnancy presents an opportunity to address these problems by opportunistic assessment, facilitating referral to specialist services, coordinating and providing transport to appointments to assist with attendance.
Comorbid medical problems
psychiatric disorders
dental problems
superficial abscess from injecting – groin, skin from ‘skin popping’ (see below)
liver problems – hepatitis C, alcoholic liver disease
lung problems from inhaling drugs
pancreatitis – alcohol
subacute bacterial endocarditis (SBE)
poor nutrition and anaemia
accidental injury when intoxicated
overdose
Poverty and social deprivation are often associated with substance misuse, which in turn worsens social circumstances. These circumstances often pose the most pressing problems, and help should be offered in parallel with medical care.
Social problems
Women can be helped to access services such as adult education programmes, the benefit agency, housing services and legal services as needed.
Holistic care should include the care of the partner and existing children. Partners who misuse substance should be encouraged to seek help. Smoking cessation advice should be given to both parents. General enquiries about other children should also be made, for example about their motor or speech development or schooling. The aim is not to provide comprehensive services for the whole family through the maternity services, but to be alert to any obvious or serious problems.
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