Substance Misuse

Question 1

What are the effects of smoking in pregnancy?

Answer 1

FGR / SGA (most significant — dose-dependent)
Miscarriage
Ectopic pregnancy
Placenta praevia
Placental abruption
Preterm birth
Stillbirth
PPROM
Low birth weight
Sudden infant death syndrome (SIDS)
Childhood asthma/respiratory problems
Management: Offer nicotine replacement therapy (NRT) — safe in pregnancy. Refer to stop smoking services. Varenicline and bupropion — limited safety data; generally avoid.

Question 2

What are the effects of alcohol in pregnancy?

Answer 2

Fetal Alcohol Spectrum Disorder (FASD):
Growth restriction
Facial features: smooth philtrum, thin upper lip, short palpebral fissures
Microcephaly
Neurodevelopmental problems (learning difficulties, behavioural problems, ↓IQ)
Cardiac defects (VSD)
Renal abnormalities
Skeletal abnormalities
No safe level identified
Chief Medical Officer: safest not to drink at all in pregnancy

Question 3

What are the effects of cocaine/crack use in pregnancy?

Answer 3

Vasoconstriction → placental abruption (most significant)
Miscarriage
Preterm labour
FGR
Stillbirth
Intracranial haemorrhage (maternal or fetal)
Pre-eclampsia
Uterine rupture
Neonatal withdrawal (less severe than opioids)

Question 4

What are the effects of opioid use in pregnancy and how is it managed?

Answer 4

Effects:

FGR
Preterm birth
Stillbirth
Neonatal abstinence syndrome (NAS) — irritability, high-pitched cry, tremor, poor feeding, diarrhoea, seizures (onset 24-72 hours after birth)
Management:

Do NOT abruptly stop opioids (risk of miscarriage, preterm labour, stillbirth)
Refer to specialist drug and alcohol services
Substitute with methadone (or buprenorphine) — oral supervised consumption
Aim for stable dose; gradual reduction if desired
Neonatal team aware; baby monitored for NAS using Finnegan scoring
Breastfeeding generally safe on stable methadone (not with active illicit drug use)