Version July 2025
INTRODUCTION —
Use and misuse of substances by pregnant individuals occurs globally. Identification of substance use allows for interventions aimed at reducing maternal and fetal risk by reducing or discontinuing substance use and initiating treatment when indicated. Challenges to care of people who use substances during pregnancy include a lack of screening tools that function across cultures and languages, barriers to patient disclosure of substance use, and limited treatment and risk reduction resources that have strong supporting evidence.
This topic will explore the impact of selected substances on pregnancy. Screening for substance use and laboratory testing are discussed separately.
●(See "Substance use during pregnancy: Screening and prenatal care".)
●(See "Urine drug testing".)
Related content specific to alcohol and opioid use in pregnancy are presented elsewhere.
●(See "Alcohol intake and pregnancy".)
●(See "Fetal alcohol spectrum disorder: Clinical features and diagnosis".)
●(See "Opioid use disorder: Overview of treatment during pregnancy".)
●(See "Neonatal abstinence syndrome (NAS): Management and outcome".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender-expansive individuals.
CHALLENGES IN ASSESSING DRUG IMPACT —
A dose-dependent effect of any illicit or misused substance on pregnancy outcome is difficult to ascertain because data are scarce and confounded by the influence of other factors, including use of other substances, poor nutrition, poverty and related adverse stressors, comorbidities, inadequate prenatal care, and environmental factors, such as the COVID-19 pandemic, which saw an increase in overdose deaths in pregnant persons [1]. In addition, reliable ascertainment of the extent of substance use during pregnancy and drug dose/purity are very difficult.
The clinical manifestations of substance use disorders are diverse and differ by drug and setting (eg, usual dose, overdose, withdrawal). Combined with the physiologic changes of pregnancy and the clinical manifestations of coexisting pregnancy-related disease, diagnosis of patients presenting with serious clinical abnormalities can be challenging. For example, cocaine and amphetamine overdose can cause hypertension and seizures, similar to preeclampsia/eclampsia.
OPIOIDS —
An online patient-oriented infographic is available to help with screening and counseling for opioid use disorder in pregnancy.
Prevalence — While opioid use is a global problem, opioid use by pregnant individuals living in the United States is an ongoing public health crisis.
●A US cohort study of nearly 22,000 pregnancies occurring between 1990 and 2021 reported an overall opioid exposure rate of 2.8 percent [2].
●By 2017, the estimated rate of maternal opioid-related diagnoses (MOD) had increased by nearly 5 per 1000 delivery hospitalizations compared with 2010, from 3.5 (95% CI 3.0-4.1) to 8.2 (95% CI 7.7-8.7) [3]. Analysis of discharge records from 47 states and the District of Columbia found MOD rates ranged from 1.7 (Nebraska) to 47.3 (Vermont) per 1000 delivery hospitalizations.
●Dispensing of prescription opioids to pregnant individuals decreased in the United States from 2000 to 2020. Rates of opioid prescribing and dispensing continue to be higher in publicly insured pregnant individuals (rate of 191 in 1,000 pregnancies) as compared with those who are privately insured (rate of 88 in 1,000 pregnancies) [4].
While some countries reported decreasing prevalence of opioid use during similar time periods, prevalence rates varied by income groups and did not drop for individuals in the lowest quintile of area-level income [5]. At least one study has reported higher opioid prescriptions for individuals also prescribed psychotropic medications compared with those who were not (26.5 versus 10.7 percent) [6]. (See "Opioid use disorder: Epidemiology, clinical features, health consequences, screening, and assessment".)
Complications from use — Multiple obstetric complications have been associated with opioid use disorder in pregnancy [7-9]. However, it is difficult to establish the extent to which these problems are due to opioids, opioid withdrawal, or other drugs used versus coexistent maternal medical, nutritional, psychological, and socioeconomic issues. For example, one study reported the increase in maternal cardiac events from 2002 to 2014 paralleled the rise in opioid use among pregnant persons in the United States, which raised questions about possible causality [10].
Pregnancy-associated complications include:
●Abruptio placentae
●Fetal death
●Intraamniotic infection
●Fetal growth restriction
●Fetal passage of meconium
●Preeclampsia
●Premature labor and birth
●Premature rupture of membranes
●Placental insufficiency
●Miscarriage
●Postpartum hemorrhage
●Septic thrombophlebitis
Unrelated to pregnancy, opioid use disorders are associated with risks, including financial, social, and psychological issues, that cause psychosocial stress, exposure to violence [11], and limit treatment and other life options [12].
Medication for opioid use disorder — The American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine recommend treatment of opioid use disorder in pregnancy with medications rather than medically managed withdrawal or detoxification [13].
●Medication preferred to ongoing substance use – For pregnant patients with opioid use disorder, medication treatment with methadone or buprenorphine offers overwhelming advantages (eg, oral administration, known dose and purity, safe and steady availability, improved maternal/fetal/neonatal outcomes) compared with continued use of heroin or other illicit opioids.
●Options of buprenorphine or methadone – Both buprenorphine and methadone have proven efficacy in treating pregnant patients with opioid use disorder; neither is clearly superior as each has benefits and drawbacks (table 1). Advantages of buprenorphine include less severe neonatal opioid withdrawal syndrome and somewhat lower risk of congenital malformations (approximately 1 fewer malformation per 100 neonates) in children born to individuals treated with buprenorphine compared with methadone [14,15]. Methadone has been used in pregnant patients significantly longer than buprenorphine. Historically, buprenorphine monotherapy has been preferred over the buprenorphine/naloxone combination during pregnancy. However, a large population-based cohort study in the United States from 2000 to 2018 found combination treatment to be a safe option with equal if not more favorable neonatal and maternal outcomes [16]. The safety and efficacy of long-acting injectable buprenorphine during pregnancy has not been established. Naltrexone, a third US Food and Drug Administration (FDA)-approved medication for opioid use disorder, may be safe for continuation during pregnancy, although more data are necessary to make this determination [17]. Naltrexone is not currently recommended for initiation during pregnancy.
Regardless of which medication is chosen to treat opioid use disorder, treatment with medical therapy presents a unique opportunity to bring women into medical and obstetric care systems. Clinical use of methadone and buprenorphine in pregnant patients, as well as fetal/neonatal effects, are discussed in detail separately.
●(See "Opioid use disorder: Overview of treatment during pregnancy".)
●(See "Opioid use disorder: Pharmacotherapy with methadone and buprenorphine during pregnancy".)
●(See "Neonatal abstinence syndrome (NAS): Management and outcome".)
CANNABIS (MARIJUANA) —
An online patient-oriented infographic is available to help with screening and counseling for cannabis use in pregnancy.
Advisory during pregnancy — Cannabis use during pregnancy does not provide clear benefit to the pregnant person or fetus and there is growing evidence that use may be harmful to both. The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the Academy of Breastfeeding Medicine (ABM) advise avoiding cannabis use during pregnancy and lactation because of concerns for the neurodevelopmental impact on the developing fetus and child [18-20]. Potential risks are of particular concern for pregnant individuals as there are data supporting increasing potency of cannabis products, including cannabidiol-only products, and that combined use of cannabis and nicotine products during pregnancy is associated with increased fetal risks compared with use of either product alone [21-24].
Epidemiology — Cannabis (marijuana) is one of the most commonly used substances during pregnancy [19].
Prevalence and risk factors for use — Prevalence of pregnancy-specific use varies according to maternal age, racial or ethnic background, and socioeconomic status.
●Any use – Self-reported rates of use vary from 2 to 7 percent in many studies to approximately 30 percent among young, urban, and socioeconomically disadvantaged individuals [25-36]. In a US national survey from 2013 to 2019, the percent of pregnant persons reporting cannabis use ranged from 4.9 percent (in the past month) to 15.2 percent (in the past year) [37]. By comparison, among nonpregnant women, 11.8 percent reported marijuana use in the past month, and 19.5 percent in the past year. After adjusting for sociodemographic characteristics, past-year marijuana use was 2.3 to 5.1 times more likely among pregnant persons, and 2.1 to 4.6 times more likely among nonpregnant women reporting past-year tobacco smoking, alcohol use, or other illicit substance use compared with those without other substance use. Areas that have legalized the recreational use of cannabis have also seen an increase in rates of cannabis use during pregnancy [38,39].
●Cannabis use disorder – One United States study of self-reported survey data noted that, among pregnant individuals who reported cannabis use in the past year, 18 percent met criteria for Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) cannabis abuse and/or dependence [30]. Another study reported that 26 percent of patients who tested positive for cannabis at delivery met criteria for a cannabis use disorder per DSM-5 criteria [40]. Depression and anxiety have been associated with cannabis use in pregnancy [41-43].
●Nausea as a risk factor – Multiple studies have reported that nausea and vomiting in pregnancy may be a risk factor for prenatal cannabis use [44,45]. Paradoxically, chronic cannabis use can also cause a hyperemesis syndrome, of which patients and clinicians may be unaware [46]. Nausea may also be a withdrawal symptom for those who stop using cannabis after frequent or heavy use [45]. (See "Cannabinoid hyperemesis syndrome".)
●Impact on reproductive health – Cannabis may impact both male and female fertility and has been associated with abnormal embryo implantation and development [47,48].
Evidence of increasing use — Cannabis use by pregnant persons has been increasing, possibly related to perceived lack of risk, legalization, and changing social attitudes [32,33,36,49-51].
●Increasing use – Reviews of United States data demonstrate rising rates of cannabis use among pregnant individuals. Between 2001 and 2022, prenatal use rates were 3.4 percent (2001-2002), 5.5 percent (2012), 7 percent (2016-2017), and 9 percent (2022), while rates of alcohol and cigarette use dropped during the same time period [32,36,52,53]. While toxicology tests demonstrate higher use rates compared with self-report [36,54], both methods identified increases in prevalence of use from 2012 to 2022 [36].
●Variations in use by race, ethnicity, and age – Increasing rates of prenatal cannabis use have been reported across multiple racial, ethnic, and age groups, which further highlights the need for a universal approach to education, screening, and intervention. In a study of pregnant persons from the Kaiser Permanente Northern California system who were universally screened for cannabis use with self-report and urine toxicology testing, prenatal cannabis use increased between 2012 and 2022 for all demographic groups and overall (overall cannabis use in 2012: 1846 patients, 5.5 percent; in 2022: 3885 patients, 9.0 percent; adjusted prevalence ratio 1.82, 95% CI 1.72-1.91) [36]. In 2012 and 2022, the lowest prevalence rates were in Asian individuals (0.7 and 2.4 percent) and those aged ≥ 35 years (2.5 and 5.0 percent), while the highest prevalence rates were for Black individuals (20.2 and 29.3 percent) and those aged ≤ 24 years (15.3 and 23.1). In adjusted analysis, lower increases in prevalence were reported for groups starting with the highest use in 2012 (Black individuals and patients aged ≤ 24 years).
●Clinical importance – Any increase in use is important because approximately 50 percent of women who use cannabis will continue to do so while pregnant and there is evidence of increasing potency of cannabis [21,22,55]. In a 2017 review of the United States Pregnancy Risk Assessment Monitoring System (PRAMS), 9.8 percent of women reported cannabis use prior to pregnancy, 4.2 percent during pregnancy, and 5.5 percent after pregnancy [34]. (See "Cannabis use and disorder: Epidemiology, pharmacology, comorbidities, and adverse effects".)
Perceived lack of risk — A study from the US NSDUH database reported that the percentage of females who believed that regular cannabis use was of no risk during pregnancy increased from 4.6 percent in 2005 to 19.0 percent in 2015 [56]. In addition, a qualitative study found that patients reported trust in cannabis retailers and perceived them as being "knowledgeable, nonjudgmental, and caring" [57]. A 2022 US population-based survey reported that living in a state requiring point-of-sale warning signs appeared to have opposite effects on the prevalence of beliefs about cannabis impact during pregnancy, with pregnant women who used cannabis having a greater prevalence of beliefs that cannabis was safe and those who did not use cannabis during pregnancy having a greater prevalence of beliefs that use was unsafe [58].
The previous studies highlight the importance of obstetric providers offering education about the potential risks of prenatal cannabis use. Obstetric professionals have access to the most recent and accurate findings and can serve as objective experts, particularly since people who use cannabis appear to find warning labels unconvincing and rely instead on cannabis retailers for information.
Pharmacokinetics — Chemical products from cannabis use are transferred both across the placenta and into breast milk [59-62]. One study of 54 breast milk samples collected from women who used cannabis between 2014 and 2017 reported that over 60 percent of milk samples had detectable levels of delta-9-tetrahydrocannabinol (delta-9- tetrahydrocannabinol [THC]) up to approximately six days after last reported cannabis use [63].
●Animal data – In rat models, fetal plasma levels were approximately 10 percent of maternal levels after acute exposure to delta-9-THC, the primary psychoactive cannabinoid [64]. However, repetitive exposure of THC resulted in higher fetal levels.
●Human data – In comparison with animal models, studies assessing the impact of cannabis use on humans may be confounded by polysubstance use, socioeconomic factors, and the multiple chemicals present in cannabis smoke, which may be present in greater concentrations than in regular tobacco smoke [65].
●Increasing potency – In addition, contemporary cannabis products have higher quantities of THC compared with previous decades of study [21,22,66].
•A meta-analysis of 12 studies of samples from global cannabis markets reported increasing delta-9-THC concentrations in cannabis herbal and resin products between 1970 and 2017 [22].
•An evaluation of illicit cannabis products seized in the United States reported an increase in high cannabidiol (CBD)-containing substances with an increase in overall potency from approximately 10 percent in 2009 to approximately 14 percent in 2019 [21].
Detailed discussions of pharmacology and toxicity of acute cannabis use are presented elsewhere. (See "Cannabis (marijuana): Acute intoxication", section on 'Pharmacology and toxicity'.)
Assessment of use — Screening for substance use is covered in detail in related content.
●(See "Substance use during pregnancy: Screening and prenatal care".)
●(See "Urine drug testing".)
Briefly, methods to assess maternal cannabis use include patient self-report (medical history, survey) and laboratory test (urine, saliva, cord blood, meconium). Urine testing may identify both recent, infrequent use (eg, within the past two to three days) or chronic use, given cannabis's long half-life. Among individuals with chronic cannabis use, a positive urine toxicology screen may reflect either a new episode of use or continued excretion of residual drug [67,68]. Use of tetrahydrocannabinol (THC) analogs (delta-8-THC, delta-10-THC) may not present on certain urine drug screens depending on the specificity of the test. Umbilical cord homogenate and meconium detect cannabis use from the second trimester onward [69]. Cord testing for the most stable metabolite, 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid, is widely used clinically. Laboratory testing typically exceeds self-report, even in states with legalized use of cannabis. For example, a cross-sectional study of 116 females giving birth in Colorado, where cannabis use is legal, reported that 22 percent had detectable 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid cord levels while far fewer self-reported use (6 percent reported use in the past month by survey and 3 percent by medical history) [70]. (See "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment", section on 'Drug testing'.)
Obstetric outcomes — The body of evidence from large population studies suggests an increasing risk of spontaneous preterm birth and small for gestational-age infants with prenatal cannabis exposure [35,53,71-78]. The impact of prenatal cannabis use on obstetric outcomes is difficult to assess because of conflicting observational data, historically small study sizes, reliance on self-reported use, wide ranges of substance exposure (eg, dose, frequency), and multiple confounding factors (eg, tobacco, alcohol, and, other substance use) [23,71,79,80]. Findings also indicate greater risk of gestational hypertension, preeclampsia and placental abruption [81]. Another limitation is that causality cannot be inferred from observational data. As an example, a study of pregnant persons with laboratory-confirmed cannabis exposure reported that ongoing use beyond the first trimester and higher levels of urine THC-COOH were associated with greater odds of depressive symptoms between 22 and 29 weeks gestation, but the study design prevented understanding the direction of association or causation [82].
Representative data include:
●Studies reporting increased risk – The studies below support increased risk of adverse obstetric outcomes but the magnitude of impact is less clear given high heterogeneity of the available data.
•A retrospective cohort study including 316,722 pregnancies and 250,221 unique individuals reported that cannabis use (n = 20,053), compared with nonuse (n = 296,669), was associated with increased risk of placental abruption (adjusted risk ratio [aRR] 1.19, 95% CI 1.05-1.36), gestational hypertension (aRR 1.17, 95% CI 1.13-1.21, preeclampsia (aRR 1.08, 95% CI 1.01-1.15), and weight gain less than (aRR 1.05,95% CI 1.01-1.08) and greater than (aRR 1.09, 95% CI 1.08-1.10) guidelines [81]. Rates of cannabis use were 6.7 percent overall, 2.9 percent by self-report, 5.3 percent by toxicology testing, and 1.8 percent by both. The reported frequency of cannabis use was daily (0.6 percent), weekly (0.7 percent), monthly or less (1.5 percent), unknown (3.4 percent), and never (93.7 percent).
•A 2023 meta-analysis reported prenatal cannabis use was associated with increased risks of spontaneous preterm birth (odds ratio [OR] 1.68, 95% CI 1.05-2.71, I2 99%), low birth weight (OR 2.60, 95% CI 1.71-3.94, I2 99%), and admission to a neonatal intensive care unit (OR 2.51, 95% CI 1.46-4.31, I2 100%) [72]. Limitations include low certainty evidence because of multiple differences in measuring cannabis use, imprecision as reflected in wide confidence intervals, and inherent risk of bias from observational data.
•A 2022 meta-analysis of studies from 1983 to 2020 reported increased risk of small-for-gestational age birthweight for neonates exposed to prenatal cannabis compared with unexposed infants (<fifth percentile by birth weight, risk ratio 1.61, 95% CI 1.44-1.79, six studies, n = 22,928 patients, i2 = 0 percent) [73]. While prenatal cannabis use was also significantly associated with increased risks of preterm birth (<37 weeks gestation), low birth weight, lower absolute birth weight, and reduced head circumference, these results had high levels of heterogeneity and the impact of chance could not be excluded.
●No increased risk – Older studies have reported no increased risk in adverse obstetric outcomes [79,83]. In a 2016 meta-analysis of 31 studies that compared birth outcomes after cannabis use in pregnancy with no use during pregnancy, pooled adjusted analysis reported no increased risk for low birth weight (pooled relative risk 1.16, 95% CI 0.98-1.37) or preterm birth (pooled relative risk 1.08, 95% CI 0.82-1.43) [79]. Adjusted confounding factors included maternal tobacco smoking, other substance use, and selected socioeconomic and demographic factors. Limitations of this meta-analysis included relatively few individuals in the risk-adjusted group and focus on only two birth outcomes at a time when cannabis products may have been of lower potency.
●Potential mechanism – A least one study comparing ultrasound findings in individuals who used cannabis daily with those who did not use reported increased placental vascular resistance, which may be one mechanism of impaired growth in exposed fetuses [84]. Animal studies also suggest that the endocannabinoid system plays a significant role in potential placental dysfunction and adverse pregnancy outcomes [85].
Neonatal and pediatric outcomes — In contrast with obstetric outcomes, data suggest that cannabis use during pregnancy negatively impacts fetal/neonatal outcomes and that risk of poor outcome may be dose-dependent [86]. For the reasons detailed below, ACOG and ABM discourage cannabis use during breastfeeding [18,19]. Additional patient information can be found through ACOG's website. (See "Neonatal abstinence syndrome (NAS): Clinical features and diagnosis", section on 'Cannabis' and "Neonatal abstinence syndrome (NAS): Management and outcome", section on 'Cannabis'.)
●Neonatal morbidity or death – Maternal cannabis use and cannabis use disorder (CUD) have been associated with increased risk of neonatal death (death within 28 days after birth) and infant death (death within one year of birth). More research is needed to understand mechanisms by which maternal cannabis use negatively impacts offspring morbidity separate from potential confounders, such as living situations.
•Cannabis use only – A retrospective study that evaluated perinatal outcomes of over 3 million births based on prenatal exposure to cannabis only, nicotine only, or a combination of both, compared with unexposed individuals, reported similar rates of neonatal and infant death among cannabis-exposed, nicotine-exposed, and unexposed individuals (cannabis-only or nicotine-only: neonatal death 0.3 percent and infant death 0.7 percent; unexposed infants: 0.2 and 0.3 percent, respectively) [23]. A different California birth registry study including over 34,000 births to patients with cannabis-use disorder (CUD) reported increased risk of infant death with maternal CUD compared with no exposure (1.0 versus 0.4 percent, adjusted risk ratio [aRR] 1.4, 95% CI 1.2-1.6) [87]. Exposure dose may have contributed to the different outcomes.
•Combined use of cannabis and nicotine products – Prenatal exposure to both cannabis and nicotine products appears to further increase risk of neonatal and infant death. The retrospective study (cited above) reported increased rates of neonatal and infant death with combined exposure compared with single-agent exposure (neonatal death: 0.6 versus 0.3 percent, aRR 1.76, 95% CI 1.36-2-28; infant death: 1.2 versus 0.7 percent, aRR 2.18, 95% CI 1.82-2.62) [23].
●Neurobehavioral outcomes – A growing body of literature suggests perinatal cannabis use is associated with detrimental neurobehavioral outcomes in some studies [85,88-96], although some studies have reported no effect [90,91]. Limitations to definitive conclusions include the observational nature of the data, cannabis assessment with self-report versus urine testing, and duration of follow-up. Studies have suggested a range of neurodevelopmental differences, including autism spectrum disorder [97], disruptive behavior disorders [96], poor executive functioning [95], heightened aggression [95], psychotic-like experiences [92], and mood disorders [93,94]. As one example, in a retrospective study of over 500,000 pregnant Canadian persons, cannabis use was associated with an increased risk of autism spectrum disorder (exposed versus unexposed children, 4.00 versus 2.42 per 1000 person-years; adjusted hazard ratio 1.51, 95% CI 1.17-1.96) [97].
Short- and long-term effects of maternal cannabis use on offspring are reviewed in detail separately.
•(See "Neonatal abstinence syndrome (NAS): Clinical features and diagnosis".)
•(See "The substance-exposed child: Clinical features and diagnosis".)
●Congenital anomalies – While available data do not suggest an increase in congenital anomalies among children born to people who use cannabis, the findings are mixed, limited by studies including relatively small numbers of individuals who only used cannabis, and complicated by confounders, such as lower supplemental folic acid intake among people who use cannabis [26,85,98-102]. While one meta-analysis reported increased risks of Ebstein anomaly and gastroschisis for people who used cannabis compared with those who do not use cannabis, further verification is needed, as available data were limited (adjusted odds ratio [aOR] Ebstein anomaly 2.19, 95% CI 1.25-3.82, two studies and gastroschisis aOR 2.50, 95% CI 1.09-5.74, five studies) [103].
COCAINE
Use — Although data suggest that cocaine and other stimulant use is increasing globally [104,105], many more pregnant individuals smoke cigarettes, drink alcohol, or smoke cannabis than use cocaine [106-111]. (See "Cocaine use disorder: Epidemiology, clinical features, and diagnosis".)
Impact on pregnancy — Cocaine crosses the placenta and fetal blood-brain barrier; vasoconstriction is the major purported mechanism for fetal and placental damage [112]. The applicability of any of the studies on cocaine use in pregnancy is limited by methodologic shortcomings, such as failure to control for maternal age, parity, socioeconomic factors, and exposure to other drugs, alcohol, and cigarettes.
The few adequately controlled reports suggest that cocaine's effects are related to dose and stage of pregnancy. A meta-analysis including 31 studies that evaluated the relationship between maternal antenatal cocaine exposure and five adverse perinatal outcomes found cocaine use during pregnancy significantly increased the risks of [113]:
●Preterm birth (odds ratio [OR] 3.38, 95% CI 2.72-4.21)
●Low birth weight (OR 3.66, 95% CI 2.90-4.63)
●Small for gestational age infant (OR 3.23, 95% CI 2.43-4.30)
●Shorter gestational age at delivery (-1.47 weeks, 95% CI -1.97 to -0.98)
●Reduced birth weight (-492 grams, 95% CI -562 to -421 grams)
Others have reported increased risks of miscarriage, abruptio placentae, and decreased length (-0.71 cm) and head circumference (-0.43 cm) at birth [114-116]. Teratogenic effects have not been definitively proven. Cocaine enters breast milk and poses risk to the nursing infant. Cocaine use during lactation is strongly discouraged [117]. (See "Neonatal abstinence syndrome (NAS): Clinical features and diagnosis", section on 'Cocaine'.)
Cardiovascular cocaine toxicity is increased in pregnant individuals [112]. Cocaine toxicity usually causes hypertension, which may mimic preeclampsia. Beta-adrenergic antagonists (ie, beta blockers) should be avoided in the treatment of cocaine-related cardiovascular complications because they create unopposed alpha-adrenergic stimulation and are associated with coronary vasoconstriction and end-organ ischemia. This contraindication includes labetalol, which has predominantly beta-blocking effects. Hydralazine is preferred for treatment of hypertension in pregnant individuals who use cocaine [118]. Decisions regarding the administration of peripartum analgesia or anesthesia need to be individualized, taking into account factors such as the combined effects of cocaine, analgesia, and anesthesia on the patient's cardiovascular and hematologic status [119].
●(See "Cocaine: Acute intoxication".)
●(See "Cocaine use disorder: Epidemiology, clinical features, and diagnosis".)
●(See "Stimulant use disorder: Treatment overview".)
AMPHETAMINES, INCLUDING METHAMPHETAMINE
Prevalence — A diagnosis of amphetamine use disorder is becoming more common among individuals of reproductive age, including hospitalized pregnant females [105,120-122].
●A study of 2011 to 2019 California health system data reported annual adjusted prevalence rates of methamphetamine use ranged from a high of 0.24 percent in 2014 to a low of 0.17 percent in 2019 (use defined as positive self-report or positive toxicology test) [105].
●In a study of US hospital discharge data, in 2014 to 2015, amphetamine use was identified in approximately 1 percent of deliveries in the rural West [123]. The study also reported amphetamine use was higher than opioid-use incidence for most areas (opioid use was higher in the Northeast). Deliveries complicated by amphetamine use had higher evidence of exposure to cannabis, cocaine, alcohol, and sedatives compared with control hospital deliveries. This study highlights the importance of screening pregnant individuals for multiple substances.
Impact — Methamphetamine (commonly known as speed, meth, or chalk, or as ice, crystal, or glass when smoked) is a powerfully addictive stimulant. It is a known neurotoxic agent that causes release of dopamine. Amphetamines and their byproducts cross the placenta [124]. No fetal structural abnormalities have been definitively associated with perinatal amphetamine exposure [125]. However, methamphetamine exposure during pregnancy has been associated with maternal and neonatal morbidity and mortality. In studies that controlled for confounders, methamphetamine exposure was associated with a two- to fourfold increase in risk of fetal growth restriction [126-128], gestational hypertension, preeclampsia, abruption, preterm birth, intrauterine fetal demise, neonatal death, and infant death [129]. A meta-analysis of eight studies that compared pregnancy outcomes for females using methamphetamines with control individuals also reported younger gestational age at birth, lower birth weight, smaller head circumference, shorter body length, and lower Apgar scores for exposed infants [130]. The meta-analysis did not find significant differences in the rates of preeclampsia and hypertensive disorders. Pregnant individuals who use methamphetamine are also at higher risk of syphilis and should be screened appropriately [131]. (See "Syphilis in pregnancy".)
Short-term neonatal effects and long-term outcomes in offspring, as well as methamphetamine use disorders and treatment of acute intoxication, are reviewed separately.
●(See "Neonatal abstinence syndrome (NAS): Clinical features and diagnosis", section on 'Amphetamines' and "Neonatal abstinence syndrome (NAS): Management and outcome", section on 'Other substances'.)
●(See "Methamphetamine: Acute intoxication".)
●(See "Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis".)
RESOURCES
●American Society of Addiction Medicine (ASAM)
●Substance Abuse and Mental Health Services Administration (SAMHSA)
●American College of Obstetricians and Gynecologists (ACOG) offers free online Frequently Asked Questions infographics addressing opioid, cannabis, alcohol, and tobacco use in pregnancy.
●Perinatal Provider Toolkit by the Mid-America Addiction Technology Transfer Center (ATTC) Network, funded by SAMHSA
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Substance misuse in pregnancy" and "Society guideline links: Opioid use disorder and withdrawal" and "Society guideline links: Cannabis use disorder and withdrawal" and "Society guideline links: Cocaine use and cocaine use disorder".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Alcohol and drug use in pregnancy (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Challenges in assessing drug impact – The effect of any illicit or misused substance on pregnancy outcome is difficult to ascertain because data are scarce and confounded by the influence of other factors, including polysubstance use (particularly alcohol and tobacco products), poor nutrition, poverty, comorbid disorders, and inadequate prenatal care. In addition, reliable ascertainment of the extent of drug use during pregnancy and drug dose/purity are very difficult. (See 'Challenges in assessing drug impact' above.)
●Opioids – Maternal opioid use disorder is associated with multiple obstetric complications, including pregnancy loss, fetal growth restriction, preeclampsia, preterm labor and birth, and fetal death. For pregnant individuals with opioid use disorder, treatment with methadone or buprenorphine should be offered; neither drug is clearly superior, but there is more experience with methadone. Medications for opioid use disorder are associated with fewer neonatal complications and side effects than medically managed withdrawal (detoxification) or continued use of nonprescribed opioids. Neonatal opioid withdrawal syndrome is typically less severe in neonates born to individuals treated with buprenorphine compared with individuals treated with methadone. Identification of opioid use and linkage to appropriate prenatal care are important for improved outcomes. (See 'Opioids' above.)
Related content on opioid use disorder in pregnancy is presented separately:
•(See "Substance use during pregnancy: Screening and prenatal care".)
•(See "Opioid use disorder: Overview of treatment during pregnancy".)
•(See "Opioid use disorder: Pharmacotherapy with methadone and buprenorphine during pregnancy".)
●Cannabis (marijuana) – Although data are mixed, observational evidence suggests that prenatal cannabis use is associated with increased rates of spontaneous preterm birth, small for gestational age, neonatal and infant death, and detrimental neurobehavioral outcomes. Thus, cannabis use is discouraged during both pregnancy and lactation although older studies reported no harm. (See 'Cannabis (marijuana)' above.)
●Cocaine – Cocaine can cause vasoconstriction of uterine vessels, which is the probable major mechanism leading to placental abruption. Abruption can lead to spontaneous abortion, preterm labor and birth, and fetal death. Increased cardiovascular cocaine toxicity has also been reported for pregnant versus nonpregnant individuals. (See 'Cocaine' above.)
●Amphetamines – Amphetamines, including methamphetamine, cross the placenta. While no fetal structural abnormalities have been definitively associated with perinatal amphetamine exposure, methamphetamine use during pregnancy has been associated with fetal growth restriction, gestational hypertension, preeclampsia, abruption, preterm birth, intrauterine fetal demise, and neonatal and infant death [35]. (See 'Amphetamines, including methamphetamine' above.)
