In this article, we are going to review the substance abuse in pregnancy.

There are 3 areas that we are concerned about. First, tobacco use in pregnancy, next alcohol abuse and then we’ll talk a little bit about illicit drugs [substance abuse]

1. Tobacco Abuse (SUBSTANCE ABUSE)

Adverse Outcomes

One of the things that are important to know if we can get our patients to stop smoking prior to 24 weeks, their outcomes are the same as someone who has never smoked.

  • So, when we think about what things can happen with tobacco abuse [substance abuse] in pregnancy, one of the big issues is placental abruption. So, tobacco abuse can affect those blood vessels in the placenta and that can cause the placenta to prematurely separate from the uterus leading to abruption.
  • One of the other adverse outcomes we see with tobacco abuse in pregnancy is preterm labour. Again, that placental abruption can cause contractions to happen and can increase our patient’s risk for delivering early.
  • Also, there’s an increased risk of preterm premature rupture of membranes also leading to early delivery.
  • Again, because tobacco abuse actually affects the blood vessels that are supplying the placenta, that can affect the growth of the baby and lead to fetal growth restriction.
  • One of the outcomes that are not quite as well understood is Sudden Infant Death Syndrome and so this is important for our patients to understand that even if they stop smoking during the pregnancy if they smoke around the infant after the infant is born, there is an increased risk of Sudden Infant Death Syndrome also known as SIDS.

Smoking Cessation – 5 A’s

So, that’s great that we’ve discussed about the things that can happen when you smoke in pregnancy but what do we do to help our patients not smoke? This is an important clinical pearl.

  • So, the first thing is we want to ask. We want to ask if they’re ready to stop smoking. If they’re ready, then we are able to move on to the next step.
  • Next is to give advice and start to advise. We want to make sure they understand the ill effects of smoking and how that can harm them and their baby.
  • Then again, we have to then make an assessment if they are ready to stop smoking, where they are in their pregnancy, how much are they smoking in the pregnancy, because that will kind of determine what we need to do to help them stop smoking.
  • So, the 4th A is Assist. We want to assist our patients in being able to stop smoking. Now sometimes the assist is to help change the behaviour. It’s not necessarily the nicotine that they are attached to that makes them smoke. So, for example, I’ve had a patient that told me that every time she takes a coffee break, she likes to smoke a cigarette. So, what we talked about was what things she could drink or eat with her coffee that might substitute that cigarette. For example, carrot sticks, candy, gum and that was successful for her.
  • Now, for other patients, it is the nicotine that they are attracted to that makes them continue to smoke. We can use nicotine patches. We can also use nicotine gum in pregnancy to help our patient stop smoking. But it’s very important to make sure that they understand that if they’re smoking and doing the nicotine that can significantly increase their blood pressure. So, we want to make sure that they are ready to stop smoking if they’re going to use these nicotine substitutes.
  • Then the 5th A, one of the most important, is to make sure that we arrange for the help that our patients need so they can stop smoking.


So, here’s a question for you.

Which of the following is not an effect of smoking during pregnancy?

A. Preterm labour

B. Preeclampsia

C. Placental abruption

D. Fetal growth restriction

Let’s think about the things we just talked about. Preterm laboR, is that one of the things that can happen? Yes. We discussed that preterm labor happens when women smoke in pregnancy. Preeclampsia, does that happen? I don’t remember talking about that one. Let’s go on to the other options. Placental abruption, remember we said that smoking can affect those blood vessels going to the placenta causing the placenta to prematurely separate, which is placental abruption, and then fetal growth restriction. Remember that tobacco again affecting the blood vessels can affect the growth of the fetus. So, preeclampsia is the one that is not caused by smoking during pregnancy.

2. Alcohol Abuse (sUBSTANCE ABUSE)

Adverse Outcomes

There are some adverse outcomes and we’re going to talk about each of these in a little bit of detail: fetal alcohol syndrome, CNS abnormalities, and then fetal growth restriction.

Fetal Alcohol Syndrome

Characteristic Craniofacial Features

So, with fetal alcohol syndrome, there are craniofacial features that you need to make sure you’re very well aware of. So, a short palpebral fissure, flat midfaces, long and flat philtrum and then also this very thin vermillion border of the upper lip.

You can also see a small head circumference, small eye opening, small midfaces and again that thin upper lip.

Screening Questions for Alcohol Abuse – TACE

So, every patient that comes in should be screened for alcohol use in pregnancy.

Not every patient is going to come in admitting that they have a problem nor will they understand that they have a problem.

So, a quick and easy way to assess if there’s an issue is the Mnemonic TACE. Now, each of these categories has a score and if a patient scores 2 or more in any of the screening, then they screen positive for alcohol abuse [substance abuse]

  • So, the first question is tolerance. So, how many drinks do you need to feel buzzed or to get drunk? If a patient needs more than 2 drinks then that is a point of 2.
  • So, annoyance means do you ever get annoyed when someone asks you about your drinking? That’s a score of 1 if the answer is yes.
  • C stands for cut down. Have you ever tried to cut down the amount that you’re drinking? If the answer is yes, that’s also a score of 1.
  • E stands for eye opener. So, have you ever needed a drink in the morning to get rid of a hangover? If the answer is yes for that, that’s also a 1.


So, which of the following is a feature of fetal alcohol syndrome?

A. Fetal hydrops

B. Palmar crease

C. Rocker bottom feet

D. Short palpebral fissure

So, when thinking about the things that we just discussed, the answer is D, short palpebral fissure.

3. Illicit Drug Abuse (sUBSTANCE aBUSE)

Some of the ones that we think of are cocaine, heroin, amphetamine, and prescription drug abuse or substance abuse.

There are several different adverse outcomes that can happen in any of these when they are used in pregnancy: Fetal growth restriction, Placental abruption and Fetal demise are the most common.

Screening for Illicit Drug Abuse – The 4 P’s

For patients that are using illicit drugs in pregnancy, there is a screening that we can use. This is called the 4 P’s.

  • So the first P stands for parents. Did they have an alcohol or drug problem, meaning the parents.
  • Next is partner, does your partner have a problem with alcohol or drugs?
  • The next P is past. Have you had a problem with alcohol or drugs?
  • Then the final P is present. Do you currently have a problem with alcohol or drugs?

Again, this is a way to find out if patients are using illicit drugs or if they’re at risk for using illicit drugs during the pregnancy.


So, here’s another question. When screening for substance abuse, which of the following questions can help determine if a patient is abusing prescription drugs?

A. Do you get annoyed when someone asks you if you are on drugs?

B. Have you ever been caught using drugs?

C. Did either of your parents have trouble with drugs or alcohol?

D. Do you know the effects of drugs in pregnancy?

So, the answer is C. Remember, one of the P’s is asking about the parent’s history of alcohol or substance abuse.