DOCUMENT RESUME ED 359 678 AUTHOR TITLE Unborn. 90 … · DOCUMENT RESUME. ED 359 678 EC 302 238. AUTHOR Cook, Paddy Shannon; And Others ... This publication offers an overview of

DOCUMENT RESUME

ED 359 678 EC 302 238

AUTHOR Cook, Paddy Shannon; And OthersTITLE Alcohol, Tobacco, and Other Drugs May Harm the

Unborn.INSTITUTION Alcohol, Drug Abuse, and Mental Health Administration

(DHHS/PHS), Rockville, MD. Office for Substance AbusePrevention.

REPORT NO DHHS(ADM)92-1711PUB DATE 90NOTE 88p.PUB TYPE Reports Descriptive (141)

EDRS PRICE MF01/PC04 Plus Postage.DESCRIPTORS *Alcohol Abuse; At Risk Persons; Breastfeeding;

Cocaine; Counseling Techniques; Drinking; *DrugAbuse; Drug Use; Heroin; Infants; Influences;Marijuana; Mothers; Narcotics; *Perinatal Influences;*Pregnancy: *Prenatal Influences; Smoking; *SubstanceAbuse; Tobacco

IDENTIFIERS *Fetal Drug Exposure; Phencyclidine

ABSTRACT

This book combines in a single volume the findings ofbasic research and clinical studies conducted on the effects ofalcohol, tobacco, and other drugs on the fetus, the mother, and thebaby after birth and through lactation. It first outlines changingperspectives on teratology (the study of causes for birth defects),as knowledge about the dangers of maternal alcohol and other drug usehas increased, and notes limitations of teratogenic research. Itreviews maternal factors that influence pregnancy outcomes.Characteristics of drugs and their risk to the fetus are discussed,focusing on genetic vulnerability of the fetus, timing of drugexposure, dosage and patterns of consumption, and chemical propertiesof drugs. Hazards of prenatal exposure to specific drugs are thenexamined, including alcohol, tobacco, marijuana, cocaine, heroin andother opioids or synthetic narcotics, phencyclidine, and prescriptionmedications. For each drug, information is provided on: suspectedmechanisms for drug damage to the fetus, effects on fertility,effects during pregnancy and delivery, effects on the newborn,effects on breastfeeding, and effects on the growing child.Suggestions are then offered for counseling women about childbearingand childrearing risks of drug use. A section titled "For MoreInformation" lists health information clearinghouses, compendiums ofresources, publications and pamphlets, sources for treatmentreferrals, and additional readings. (Contains approximately 150references.) (JDD)

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Office for Substance Abuse Prevention

U.E. DEPARTMENT OF EDUCATION01fice d Educatronst Frarch and ImprovementEDUCATIONAL RESOURCES INFORMATION

CE 4TER (ERICI

.P`.TMs oocument has been reproduced asrecetve0 from the person or oroanaalionong,nanng rl

C Wu)/ changes have been made to .rnpro,rereproduction cluahty

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ALCOHOL, TOBACCO,AND OTHER DRUGS

MAY HARM THE UNBORN

Rs U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESfe Public Health Service

,7"-zs-- Alcohol, Drug Abuse, and Mental Health Administration

2 BEST COPY AVAILABLE

.%

ALCOHOL, TOBACCO,AND OTHER DRUGS

MAY HARM THE UNBORN

Authors

Paddy Shannon CookRobert C. Petersen, Ph.D.

Dorothy Tuell Moore, Ph.D.

Edited by

Tineke Bodde Haase

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service

Alcohol, Drug Abuse, and Mental Health AdministrationOffice for Substance Abuse Prevention

Rockwall II, 5600 Fishers LaneRockville, MD 20857

r,t)

ACKNOWLEDGMENTS

We wish to acknowledge the Public Health Service officials listed below (inalphabetical order) for reviewing the draft manuscripts that preceded thispublication. We appreciate the time and feedback they provided in giving thiseffort scientific accuracy, balance, completeness, and perspective.

Charlotte S. Catz, M.D., National Institutes of HealthDorynne Czechowicz, Ph.D., and other staff of the National

Institute on Drug AbuseLoretta P. Finnegan, M.D., Office for Treatment ImprovementGary A. Giovino, Ph.D., Office of Smoking and Health, Centers

for Disease ControlCarol J.R. Hogue, M.P.H., Ph.D., Centers for Disease ControlGloria J. Troendle, M.D., Food and Drug AdministrationKenneth R. Warren, Ph.D., the National Institute on Alcohol

Abuse and Alcoholism

Special thanks go to the National Institutes of Health, Division of ResearchServices, Medical Arts and Photography Branch for the cover design.

The views expressed herein are those of the authors and may not necessarily reflectthe opinions, official policy, or position of the Office for Substance Abuse Preven-tion (OSAP); Alcohol, Drug Abuse, and Mental Health Administration; PublicHealth Service; or Department of Health and Human Services.

All material in this volume, except quoted passages from copyrighted sources, isin the public domain and may be used or reproduced without permission fromOSAP or the authors. Citation of the source is appreciated.

DHHS Publication No. (ADM)92-1711Printed 1990. Reprinted 1992.

Foreword

During pregnancy, most drugs taken by the mother, including alcohol andtobacco, cross the placenta and enter the bloodstream of the developing fetus.Similarly, after birth, most drugs taken by the mother are passed on to the infantthrough the mother's milk. Not all babies show negative physical, mental, oremotional effects from perinatal exposure to drugs, but many do, and no oneknows which infants will and will not be affected.

Many excellent publications have been written in the past decade about thedangers of drinking, smoking, and taking other drugs during pregnancy. Thepurpose of Alcohol, Tobacco, and Other Drugs MayHarm the Unborn is to com-bine in a single volume the most recent findings of basic research and clinicalstudies conducted on the effects of alcohol, tobacco, and other drugs on theunborn, on the mother herself, and on the baby after birth through lactation.

This booklet is written for health care providers and all others working withyoung women of childbearing age. It is also written for volunteers active in theprevention and early intervention of drug abuse, including the abuse of beer,wine, distilled spirits, tobacco, and other drugs, be they illicit, prescribed, orover-the-counter.

Ultimately, this booklet is intended for women of childbearing age and theirpartners. I include the father because, through his own abstinence, a man canmake a major contribution to a woman's drug-free lifestyle and safe pregnancyand to their child's health.

This publication offers an overview of almost 300 scientific books and arti-cles on perinatal drug exposure. The authors have done a superb job of present-ing the material in a clear, easy -to- follow- and - retrieve format that makes thebooklet an excellent resource.

It is our sincere desire that this publication be used by many professionalsand volunteers in the field and thus help alert and motivate young women andmen to lead drug-free lifestyles to ensure a healthier life for themselves andtheir offspring.

Elaine M. Johnson, Ph.D.DirectorOffice for Substance Abuse Prevention

iii

Contents

Foreword iii

Introduction 1

Extent of the Problem 1

The Purpose of This Booklet 4

Changing Perspectives On Teratology 5

Multiple Maternal Factors Influence Pregnancy Outcomes 7

Characteristics Of Drugs And The Fetus Affect Risk 9

Genetic Vulnerability of the Fetus 9

Timing of Drug Exposure 10

Dosage and Patterns of Consumption 11

Chemical Properties of the Drug 12

Teratogenic Research Has Many Limitations 13

Animal Research 13

Research With Humans 13

Methodological Problems 14

Hazards of Prenatal Exposure to Alcohol, Tobacco, and Other Drugs 15

Alcohol 15

Suspected mechanisms of drug damage to the fetus 15

Effects on fertility 16

Effects during pregnancy and delivery 16Effects on the newborn 16

Effects on breastfeeding 19Effects on the growing child 19

Tobacco 20Suspected mechanisms of drug damage to the fetus 2!Effects on fertility 21Effects during pregnancy and delivery 22Effects on the newborn 22Effects on breastfeeding 23Effects on the growing child 23

v r,U

Contents

Marijuana 24Suspected mechanisms for drug damage to the fetus 25Effects on fertility 25Effects during pregnancy and delivery 25Effects on the newborn 26Effects on breastfeeding 27Effects on the growing child 27

Cocaine 27Suspected mechanisms for drug damage to the fetus 29Effects during pregnancy and delivery 30Effects on the newborn 31Effects on breastfeeding 33Effects on the growing child 33

Heroin and Other Opioids or Synthetic Narcotics 33Suspected mechanisms of drug effects on the fetus 35Effects on fertility 36Effects during pregnancy and delivery 36Effects on the newborn 37Effects on breastfeeding 38Effects on the growir a. child 39

Phencyclidine 40Suspected mechanisms for drug damage to the fetus 41Effects during pregnancy and delivery 41Effects on breastfeeding 41Effects on the newborn 41Effects on the growing child 42

Prescription Medications And Other Licit Substances 42FDA product-labeling information pertaining to pregnancyTranquilizers 46Barbiturates 46

Counseling Women About Childbearing and Childrearing Risks 47Summary 55

For More Information 59Selected Health Information Clearinghouses 59Compendiums of Resources 60Publications and Pamphlets 61Help With Treatment Referrals 63Recommended For Further Reading 64

Alcohol And Pregnancy 64Tobacco And Pregnancy 66Drugs and Pregnancy 68

Bibliography 71

vi

Introduction

An expectant mother hopesfor one thing more thanany other: a normal andhealthy baby. If asked

what she wants, a pregnant womanwill usually reply, "I want the baby tobe all right." Yet, many hundreds ofthousands of infants born each yearin this country may not be "all right"because they were exposed beforebirth to one or more harmful drugsused by their mothers.

Drug researchers are discoveringmore and more about persistentlearning and emotional disabilities, aswell as physical defects and healthproblems, attributable to alcohol andother drug exposure during fetaldevelopment. The Public HealthService document, Healthy People2000: National Health Promotion andDisease Prevention Objectives, namesalcohol use during pregnancy as theleading preventable cause of birthdefects.

Children may suffer other disas-trous consequences from theirmothers' abuse of alcohol and otherdrugs. Who has not read the tragicstories of boarder babies newbornsabandoned by their crack-using

mothers or of infants suffering fromperinatally contracted AIDS? Also,parental dependence on alcohol orother drugs is frequently associatedwith physical abuse and emotionalneglect of youngsters during crucialformative years. Health care workers,as well as women of childbearing ageand their partners, need to under-stand these risks in order to stem agrowing epidemic. Drug-dependentpregnant women and their infantsalso need help to improve theirchances for a healthy and satisfyinglife.

Extent of the Problem

Reliable estimates of the extent ofalcohol and other drug use by preg-nant women have been difficult toobtain. Until recently, no large-scalesurveys had been conducted; mostdata came from maternal historiesand infant birth records collected byindividual hospitals or perinatalresearch centers. The findings fromthese studies were difficult to inter-pret because of methodological dif-ferences. During 1990, the Centersfor Disease Control (CDC) and the

1

O

Introduction

National Institute on Drug Abuse(NIDA) are initiating new surveys ofin utero drug exposure to improveour understanding of this problem.

Nonetheless, surveys of currentdrug-using behavior among womenof childbearing age provide usefulindicators. Although many womenstop or reduce their consumption ofalcohol and other drugs in anticipa-tion of pregnancy, not all babies areplanned, and pregnancy may not beconfirmed for as long as 2 monthsafter conception a period duringwhich the developing embryo is par-ticularly vulnerable to drug effects.

Surveys of smoking behavior con-sistently find that approximately 30percent of women smoke at the timethey conceive a child; 1 in 4 womencontinue to smoke during pregnancy.The youngest and the poorest (espe-cially among unmarried, unem-ployed, or Black women) are theleast likely to quit or to reduce theamount they smoke while pregnant.

Drinking among women of child-bearing age (between 15 and 44years) is even more common thansmoking. Data from NIDA's 1988National Household Survey indicatethat 3 of every 5 women of childbear-ing age currently drink alcoholic bev-erages. In their peak reproductiveyears (18 to 34 years), 1 in every 10American women consumes an aver-age of 2 or more drinks a day or 14 ormore drinks a week an amount thatcould jeopardize an unborn baby.

The survey also found that nearly10 percent of women of childbearingage acknowledged using an illicitdrug during the month before the sur-vey. Women's use of cocaine hadincreased markedly since the previ-ous survey in 1985. In contrast to theuse of other illicit drugs, whichdeclined between 1985 and 1988,both daily and weekly cocaine userose in this period. Further, the agegroup having the highest proportionof current (i.e., within 30 days priorto the survey) cocaine users was 18 to25 years old primary childbearingyears for women.

When a mother uses drugs, herunborn or nursing infant is alsoaffected. During gestation, almostall drugs cross the placenta andenter the bloodstream of adeveloping baby.

Recent surveys of obstetricpatients and newborns, mostly fromhospitals in urban areas, have con-firmed alarming rates of illicit druguse during pregnancy. A pioneeringstudy of 36 hospitals across the coun-try sponsored by the Office for Sub-stance Abuse Prevention and theMarch of Dimes in 1987 found that11 percent of new mothers in theresponding facilities (range from 0.4to 27 percent) used cocaine, mari-juana, heroin, methadone, amphet-

2 9

Introduction

amines, and/or phencyclidine (PCP)while pregnant. A subsequent surveyof 18 primarily public hospitals in 15major cities by the House SelectCommittee on Children, Youth, andFamilies found a threefold to four-fold increase in the number of drug-exposed births between 1985 and1988. Based on maternal histories orurine testing of the newborn infant,the 1988 rate of drug-exposed new-borns in these hospitals ranged froma low of 4 percent in Denver, Colo-rado, to a high of 18 percent in Wash-ington, DC, and Oakland, California.

In still another study, 715 womenenrolling for public or private prena-tal care in a Florida county duringthe first 6 months of 1989 had theirurine tested for drugs. One in seventested positive for alcohol, marijuana,cocaine, or opiates. There were fewdifferences in prenatal drug use.between the wealthier women(n = 335) seen by private practition-ers and the poorer women (n = 380)being served by the public clinics.

There is some controversy abouthow accurately the rates of drug-exposed newborns from city hospitalscan be extrapolated to live births forthe Nation as a whole. Current esti-mates range from 40,000 to 75,000drug-exposed babies per year (1 to 2percent of all live births) to 375,000(11 percent of births). However,these numbers only reflect maternaluse of illicit drugs and would bemuch larger if alcohol and nicotine

were included. The President's 1990National Drug Control StrategyReport estimated that as many as100,000 cocaine-exposed babies areborn each year.

Individual facilities serving sub-populations of high-risk women con-firm similar rates of cocainemetabolites and other drugs in urinetests of newborns and their mothers.Cocaine was found in the urine speci-mens of 10 percent of the 3,300infants born in New York City's Har-lem Hospital in 1988. A Philadelphiahospital center reported that the per-centage of pregnant women withcocaine in their urine rose from 7 per-cent in 1985 to 58 percent in 1987. Areview of maternal histories andurine tests for 215 consecutively deliv-ered mother-infant pairs during a 1-week period in 1988 in Miami,Florida, found 12 percent with perina-tal cocaine exposure and 17 percentwith marijuana exposure. Nearlythree-fourths of the cocaine-usingmothers also smoked marijuana.

A 1988 study of 679 women receiv-ing prenatal care at Boston City Hos-pital found that 17 percent usedcocaine and 28 percent smoked mari-juana during pregnancy. An earlier1983 study of alcohol consumptionamong 1,711 pregnant women at thesame Boston hospital noted thatnearly 1 in 10 of these women (9 per-cent) were consuming 5 or moredrinks on some occasions and a dailyaverage at or above 1.5 drinks.

3

-.4

Introduction

Women who drank heavily whilepregnant were also more likely tosmoke and to use illegal drugs.

The Purpose ofThis Booklet

The primary purpose of this publi-cation is to provide accurate, up-to-date information for health careprofessionals and prevention workersto use in preconception, prenatal,and postnatal counseling of mothersand mothers-to-be. Potential parentsneed to know about psychoactivedrugs' effects on their fertility andsexual functioning, as well as theirimpact en pregnancy and childbirth.Mothers and fathers also need tounderstand that using alcohol, ciga-rettes, and other drugs while preg-nant increases the baby's risk fordeath, serious illness, physicaldeformities, developmental delays,and other abnormalities.

By encouraging mothers-to-be toavoid alcohol and other drugs as partof prepregnancy planning, the care-giver has a rare opportunity to pre-vent serious health consequences.Even in the earliest stages of preg-nancy, many women arc more thanusually receptive to health-relatedinformation and motivated to alterdangerous behavior. This is import-ant because quitting drug use duringpregnancy is beneficial. Even cuttingback can significantly reduce risk.

Unfortunately, some women (andtheir partners) do not respond to sim-ple advice about the harmful effectsof drugs. They may need more spe-cific treatment for drug dependenceand help in finding more positiveways to cope with life. When drugproblems are identified and success-fully handled, not only is a woman'sphysical and mental health improved,but her capacity for healthy childbear-ing and childrearing is also enhanced.

An infant with drug-related birthdefects can be difficult to care forand may need special handling. Sensi-tive guidance immediately after birthcan encourage crucial mother-infantbonding. Continued support in thepostnatal period may be necessary toestablish a caring and responsive fam-ily environment in which children canthrive.

Despite growing evidence of seri-ous and persisting consequences tooffspring from prenatal drug expo-sure, many physicians still fail to rec-ognize signs and symptoms of alcoholand other drug use in their patients.They may also be reluctant to con-firm such problems through directquestioning and laboratory testing.Clearly, caregivers must be betterprepared and motivated to interveneearly and appropriately. This bookletprovides not only facts and a perspec-tive on the reproductive hazards ofdrug use, but also some tips on howto counsel women about those risks.

4 1

1 Changing Perspectives onTeratology

Over the past 20 years,knowledge about the dan-gers of maternal alcoholand other drug use has

increased dramatically. Before the1960s, the placenta was generallyviewed as a natural barrier, protect-ing the human fetus from most toxicsubstances the mother might con-sume. But a popular over-the-counter drug, widely used inGermany and England for relievingcold symptoms, quieting sick chil-dren, and soothing the nausea ofpregnant women, shattered thisassumption. Thalidomide, taken bywomen in the fourth to sixth week ofpregnancy, was ultimately linked tothe birth of thousands of infants withmissing or deformed arms, and, lessfrequently, legs and ears.

This well publicized tragedysparked a new interest in teratologythe study of causes for birth defects.Initially, research focused mostintensely on the safety of fetal expo-sure to prescription medications,over-the-counter drugs, industrialchemicals, and pesticides. The Food

and Drug Administration (FDA)began to require information onknown or suspected risks to the fetusand newborn in a special section ofthe product-labeling data for all mar-keted drugs. This information helpsphysicians and consumers weigh thepotential benefits to the pregnant orbreastfeeding mother against possi-ble harmful effects on the unbornchild or nursing infant.

Public concern about the dangers

In utero drug exposure isassociated with an ''icreased rateamong newborns of (1) lowbirthweight, with small forgestational age length and headsize, (2) central nervous systemdamage that may delay or impc ,neurobehavioral development,(3) mild to severe withdrawaleffects, and (4) certain congenitalphysical malformations.

5 4 CI

Changing Perspectives on Teratology

from prenatal use of social drugsincreased considerably following theSurgeon General's 1980 report onThe Health Consequences of Smokingfor Women and a warning the follow-ing year that women should not drinkalcoholic beverages while carrying achild or nursing. Currently, the medi-cal literature abounds with articlesconcerning adverse effects on thenewborn from a mother's use of alco-

hol, cigarettes, and illicit drugs dur-ing pregnancy and lactation.

At the same time, the concept ofteratology has been expanded toinclude more subtle behavioral anddevelopmental abnormalities in off-spring that only become apparentlater in an infant's life. These latentdeficits and/or delays that are notobvious at birth are often referred toas neurobehavioral Prfzcts.

6I-0

Multiple Maternal FactorsInfluence Pregnancy Outcomes

n expectant mother's useof tobacco, alcohol, orother drugs is only one of

.L many risk factors associ-ated with a complicated pregnancy,congenital defects in the offspring, orboth. Other risks that must be kept inmind when assessing the likelihood ofadverse pregnancy outcomes include(1) a family or maternal history ofreproductive problems, (2) multipleprevious pregnancies within a shorttimespan, (3) concurrent medicalproblems such as sexually transmit-ted diseases (STDs), diabetes, lupus,hypertension, and heart, liver, or kid-ney disease, (4) serious overweight orsigns of poor nutrition, (5) beingunder 15 years old, (6) poor livingconditions and lack of education,(7) an unhealthy lifestyle with pooreating habits, lack of regular exercise,and excessive stress, (8) inadequateprenatal care, and (9) chronic orintense exposure to a variety ofknown teratogens in the environment(e.g., x rays, lead, pesticides).

Unfortunately, these risks areoften interrelated. A woman with one

risk for a complicated pregnancy ordefective baby is likely to have sev-eral. The risks may not be simplyadditive, either, but may interact syn-ergistically, further increasing theodds for an undesirable outcome.For example, the drug-dependentmother seldom uses only one drug.A woman who smokes is also morelikely to drink and use other psycho-active substances than a nonsmoker.

Women who smoke cigarettes,drink alcoholic beverages, or useother illicit drugs duringpregnancy increase their risks forobstetrical complications and forpremature labor and delivery.They are also more likely thanabstaining mothers to suffer fetallosses through spontaneousabortions, miscarriages, andstillbirths.

7

Multiple Maternal Factors Influence Pregnancy Outcomes

A woman who is drug dependent andpoor is also likely to be malnourishedand to have related health problems.

She is often young, unmarried, underconsiderable stress, and a disadvan-taged minority group member.

Characteristics of Drugs and theFetus Affect Risk

n addition to the health statusand lifestyle of the mother,characteristics of the develop-

-A- ing embryo/fetus and of thedrugs themselves can increase thechances of adverse outcomes in pre-natally drug-exposed babies.

Genetic Vulnerabilityof the Fetus

Most unborn babies develop nor-mally; congenital malformations arestill exceptional. Gross structuraldefects are estimated to occur in only1 to 3 percent of newborns. By thetime babies are a year old, however,this percentage doubles as more sub-tle abnormalities are diagnosed thatwere difficult to identify in theneonate.

Until the early 1940s, heredity wasthought to be the major cause of con-genital defects. Even with greatlyincreased knowledge about the ter-atogenic potential of a variety of licitand illicit drugs, as well as maternalillnesses and other environmentalagents, the causes of most birth anom-=1==.

alies and developmental defectsremain unclear. Abnormalities con-tinue to appear in the absence ofembryonic or fetal exposure toknown teratogens. In fact, about asmany birth defects are attributed tohereditary susceptibility as to prena-tal environmental causes (approxi-mately 10 to 15 percent in eachcategory).

Furthermore, not every baby that isexposed to even large amounts ofharmful drugs before birth developsserious defects. The genetic endow-ment of the developing fetus has animportant influence on the likelihoodof toxic effects occurring. In humans,fraternal twins born to alcoholicmothers have shown differentamounts of damage from the sameprenatal exposure. Animal researchconfirms that different strains of thesame species have differentresponses to in utero drug exposure.In the words of one prominentresearcher, "... it is misleading toportray the embryo as having a kindof gossamer fragility that will besilently ravaged by all alien invaders."

9

Characteristics of Drugs and the Fetus Affect Risk

It would be foolish, however, to relyon unborn babies' inherited resis-tance and resilience in the face of ourincreasing knowledge about prevent-able birth defects.

Not all babies show negative effectsfrom prenatal exposure to drugs.A variety of genetic factors in theunborn baby and maternalcharacteristics, as well asdifferences in the chemicalstruct:7-e of drugs and their usepatterns, interact to influence thevulnerability of the unborn baby.

Timing of Drug Exposure

One of the most important vari-ables affecting birth defects is thestage of the unborn baby's develop-ment when its mother consumes alco-hol, tobacco, or other drugs.

Conception occurs when a matureegg is fertilized in the fallopian tubefollowing ovulation. Before ferthiza-tion, the egg is vulnerable to toxicchemicals. However, between fertil-ization and implantation of the grow-ing and dividing egg in the lining ofthe uterus about a week after concep-tion, the tiny blastocyst is relativelyresistant to damage from drugexposure.

The embryonic phase, from aboutthe second through the eighth week

following conception, is critical fordeveloping vital organs, the brain,and other major biological systems.Within a span of only 10 daysfrom15 to 25 days after conception thebasic structure of the human centralnervous system (CMS) is differenti-ated from other organ systems.Within 20 to 30 days, the beginning ofthe skeleton, limb buds, and musclescan be seen. Between 24 and 40 daysof development, rapid progress ismade in the differentiation of eyes,heart, and lower limbs. By 60 days,other body organs are being formed.

During this stage (also called theperiod of organogenesis), the rapidlygrowing embryo is especially vulnera-ble to chemical injury. Exposure totoxic doses of some drugs may belethal, resulting in spontaneous abor-tion. Alternatively, malformationsmay occur in the most susceptibleorgans or limbs at the time of drugexposure. Since most women do notconfirm that they are pregnant forseveral weeks or months after concep-tion, they should be advised to avoidall unnecessary drug use as part ofpreconception planning. It is sus-pected, for example, that the thirdpostconception week of human preg-nancy is the critical period for the ter -atogenic actions of alcohol toproduce the most severe and charac-teristic features of fetal alcohol syn-drome (see next section).

The fetal stage of pregnancy, fromthe eighth week after conception to

10


birth, is the time of greatest neurolog-ical development and rapid weightgain by the developing baby. Drugexposure during this period is mostlikely to result in intrauterine growthretardation (IUGR) and subtle men-tal and behavioral deficits that arenot as apparent as gross retardationand not immediately detectable atbirth.

Dosage and Patterns ofConsumption

A fundamental premise in thestudy of drugs is that there is a dose-response relationship between thedegree of exposure and the effectsproduced. This also holds true forthe fetus effects are generally moretoxic at higher doses, ranging fromminimal, unobservable responsesthrough functional impairments andmalformations to death. Researchersare uncertain of the minimal dosebelow which maternal use of particu-lar drugs may be relatively safe forthe fetus. There is general agree-ment, however, that the risks to theunborn child are greatly increasedwhen the expectant mother consis-tently consumes large doses of harm-ful drugs or periodically binges.

A variety of factors affect theunborn baby's exposure level whenthe mother takes drugs. First of all,drug use often fluctuates during preg-nancy. Many expectant mothers spon-taneously quit or sharply reduce their

alcohol and drug consumption in theearly weeks of pregnancy because ofnausea and other unpleasant reac-tions, as well as out of concern forthe unborn baby's health. Second,although most abusable drugs thatact on a mother's brain also cross theplacenta and reach the fetus, animalresearch has demonstrated importantdifferences among drugs in the rateand extent of this placental transfer.Alcohol and opioids, for example,appear to effect the fetus more rap-idly than marijuana.

The way the drug is taken also

After the eighth week of pregnancy,maternal drug use is morefrequently associated withgrowth-retardation, prematurity,and neurological damage to theinfant. Drug use near the time ofdelivery may precipitate labor andcan be hazardous.

affects the amount that reaches thefetus. Drugs taken by mouth do notenter the mother's bloodstream andcross the placenta as rapidly as thoseinhaled or injected and may reachthe fetus in lower concentrations. Inaddition, a pregnant woman and herunborn baby may have different con-centrations of a substance in their sys-tems because of constantly changingabilities in the developing fetus toclear drugs from its own body. Preg-

11

Th

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nancy may also alter the mother'smetabolism of drugs, thereby dimin-ishing or enhancing their effects.

Chemical Properties ofthe Drug

Drugs also differ in the types ofembryonic or fetal responses they typ-ically produce, especially at differentconcentrations. Some, like alcohol,seem to produce a full range of dose-related effects in the develop:ng babythat rather closely reflect toxicresponses in the mother. Cihers, likethalidomide and vitamin A deriva-tives (Accutane), are highly toxic orlethal to the embryo or fetus at dosesin the therapeutically prescribedrange for the mother. Still otherdrugs produce abnormalities only at

Many women do not even realizethey are pregnant during the earlyweeks of pregnancy when the majorskeletal and organ systems areforming and are most vulnerable totoxic effects from drug exposure.

,....1.WPAW.W.S.A.WWW

specific sites (e.g., cleft palate), aswell as being stage- and dose-depen-dent. Some abusable drugs (e.g., mar-ijuana, heroin, methadone, nicotine)are not so frequently associated withgross structural malformations in pre-natally exposed babies as with defi-cits and delays in neurobehavioralfunctioning.

12

,0-,

ms,........-^....

Teratogenic Research HasMany Limitations

Afield of intense new inter-est is often marked byconflicting reports andcontroversy until scien-

tists have had time to confirm initialfindings. The study of prenatal drugeffects is particularly difficult, notonly because of its newness and theconstant media attention, but alsobecause of methodological limita-tions. Controlled drug experimenta-tion with pregnant mothers is out ofthe question for obvious ethical rea-sons, but there are other problemswith laboratory findings and surveytechniques. The following difficultiesshould be kept in mind as nzwreports appear.

Animal ResearchAnimal studies are important in

teratogenic research. Scientists exper-iment with mice, rats, sheep, dogs,and other small animals to reproduceand confirm observed or suspectedhazards to prenatally drug-exposedhuman babies. Carefully controlledlaboratory conditions that cannot bereproduced in clinical studies are cru-cial for understanding the mechanisms

of teratogenicity, as well as for testingthe safety of new therapeutic drugs.

Unfortunately, animal data are notalways reliable predictors of develop-mental hazards to humans. No ani-mal has a reproductive system exactlylike that of a woman, and the repro-ductive effects of drugs in animals arenot always the same as in humans. Spe-cies differences in drug reactions cansometimes be minimized by testingmore than one species.

Laboratory experiments seldomreplicate the natural conditionsunder which humans use drugs. Ani-mals, for example, are often givendoses far in excess of those used byhumans. Drugs are also administeredquite differently from usual humanconsumption methods (e.g., drippedinto animals' veins or added to theirfood rather than smoked or snorted).

Research With HumansRetrospective, after the fact, sur-

veys of mothers with defective off-spring, as well as prospective studiesof pregnant women, also have limita-tions. Self-reported drug use may beinaccurate. Mothers may have diffi-

13

Teratogenic Research Has Many Limitations

spring, as well as prospective studiesof pregnant women, also have limita-tions. Self-reported drug use may beinaccurate. Mothers may have diffi-culty remembering how much, oreven what, substances they took dur-ing a pregnancy that may haveoccurred many months or even yearsbefore. Pregnant women, particularlyif they are dependent on alcohol orother drugs, may be unwilling, or un-able, to reveal the true extent of theirdrug use. They may be unreliable inreporting the amounts they drink orsmoke and may simply not know thepurity of illicit drugs they take.

The questions researchers ask, andhow they are asked, sometimes affectthe accuracy of women's responses.While urine testing is a more reliableindicator, analysis of occasional speci-mens or those taken at delivery isnot sufficient to track changing drugpatterns throughout the pregnancy.

Even more importantly, it is verydifficult in clinical studies to separaterisks for abnormal birth outcomesassociated with prenatal exposure toalcohol and other drugs from otherinteractive factors related to themother's lifestyle and living condi-tions. Pregnant women in these stud-ies frequently use a variety of drugs

together or sequentially and havemany other risk factors for fetalimpairment that make it virtuallyimpossible to attribute teratogeniceffects of drug exposure to any singlesubstance.

Methodological Problems

Another problem with humanresearch is the small number of casesavailable for some studies. Those sub-jects who agree to participate maynot be representative of the drug-using group under study. This is espe-cially likely when studying illicitsubstances. As a result, the early find-ings regarding effects of prenatalPCP or crack exposure, for example,are unlikely to be as consistent andvalid as those based on 20 years ofwell-controlled, large-scale, and repli-cated research on the effects of ciga-rette smoking or alcohol use.

There are also measurement prob-lems in this type of research. Forinstance, gestational age is not alwaysconsidered when reporting thenewborn's length and weight. Measur-ing other defects in newborns can bevery difficult too. Repeated testingmay be necessary to determinewhether the damage is temporary orpermanent. If improvement occurs, itis sometimes hard to know whetherthe change is due to natural matura-tion or to some form of intervention.

There is little agreement amongresearchers on how smoking anddrinking patterns should be catego-rized (e.g., what is heavy or moderateconsumption?). Statistical groupingsmay not accurately reflect someindividuals' potentially very danger-ous alternating patterns of binges andabstinence. Use patterns for illicit

14

21

Hazards of Prenatal Exposure toAlcohol, Tobacco, and

Other Drugs

The following sections brieflysummarize the known orstrongly implicated dan-gers to expectant mothers

and their offspring from alcohol,tobacco, and other drug use duringpregnancy and while nursing.Because the potential for harmfuleffects is not completely establishedand use of these drugs has no healthbenefits, the safest recommendationis for women to avoid these sub-stances before conception, duringpregnancy, and while breastfeeding.

Alcohol

Beverage alcohol (ethanol) is socommon in our society that we sel-dom think of it as a drug. Yet beer,wine, liquor, and the new wine cool-ers are all central nervous systemdepressants. Thr;y are similar to bar-biturates and other sedative drugs inslowing down bodily functions suchas heart rate and respiration. When

consumed in small quantities, alcoholinduces feelings of well-being, conviv-iality, and relaxation. Bnt in largeramounts, it progressively causes intox-ication, stupor, unconsciousness, and,sometimes, respiratory arrest anddeath. Chronic, heavy drinking canseriously damage the body and isassociated with liver disorders, poornutrition, high blood pressure, heartdisease, and deficiencies in thebody's immune response, as well ashaving serious effects on brainfunctioning.

Suspected mechanisms of drug dam-age to the fetus: Numerous animalstudies demonstrate that alcohol andits primary metabolite, acetaldehyde,are directly toxic to the developingembryo and fetus and capable of pro-ducing abnormalities. Alcohol mayalso interfere with the delivery ofmaternal nutrients to the fetus, imp-air the supply of fetal oxygen,derange protein synthesis and metab-

15

Hazards of Prenatal Exposure to Alcohol, Tobacco, and Other Drugs

olism, or stimulate excess productionof certain prostoglandins that modu-late cellular functions of the bodyand could cause fetal malformations.

Effects on fertility: Chronic alcohol-ism or heavy drinking can interferewith the fertility of both men andwomen. In men, testosterone levelsand sperm counts are lowered, sexualdrive is diminished, and impotence,testicular atrophy, and gynecomastia(breast development) may also occur.The broad spectrum of alcohol-asso-ciated reproductive problems amongwomen include amenorrhea (cessa-tion of menses), menstrual cycle irreg-ularities, anovulation (cessation ofovulation), derangement of reproduc-tive hormonal functions, ovarianpathology, and early menopause.Even social drinkers who consumethree or more drinks a day are atincreased risk for menstrual cycle dys-functions.

Effects during pregnancy and deliv-ery: Alcoholic women have moreobstetrical complications, particu-larly vaginal bleeding, premature sep-aration of the placenta, and fetaldistress. Maternal alcoholism is alsoassociated with high rates of sponta-neous abortion, miscarriage, and still-birth. The risk for spontaneousabortions is dose related: pregnantwomen averaging three or moredrinks a day are more than 3 timesmore likely to miscarry than non-

drinkers. Even women who consumeonly one or two drinks a day are atincreased risk for miscarriage duringthe second trimester of pregnancy.

The effects of alcohol on prematu-rity are less conclusive. Several retro-spective studies found an associationthat has not been confirmed by largerprospective studies. However, con-suming two or more drinks per daymay increase the chances of a prema-ture delivery.

Effects on the newborn: Lowbirthweight and intrauterine growthretardation (IUGR) with shorterthan normal length and smaller headand chest circumference measure-ments accompanying the lowbirthweight are the most consis-tently observed effects of fetal expo-sure to alcohol. These problems seemmore severe among women whodrink heavily during the last 3 monthsof their pregnancy. Pregnant womenconsuming between one and twodrinks per day are twice as likely asnondrinkers to have a growth-retarded infant weighing less than 5.5pounds. Lowered birthweight andIUGR increase risks for an infant'searly death and for respiratory diffi-culties, feeding problems, seriousinfections, and long-term develop-mental problems.

Several additional factors may alsocontribute to risk for IUGR. Chronicbeer drinking during pregnancyappears to be the most significant

161^, ,Th,


determinant. Birthweight deficienciesamong newborns are also associatedwith their beer-drinking mothers'lower weight gain during pregnancy,lower weight at conception, beingBlack, and smoking cigarettes.

MS is now the leading knowncause of mental retardation. Thecognitive functioning of FASchildren with the most severe CNSinvolvement does not improve, evenwith remedial instruction.

.4140.10,10141.1K

Newborns whose mothers drinkheavily (an average of five drinks perday, especially during the last 3months of pregnancy) may show signsof alcohol withdrawal such as trem-ors, abnormal muscle tension (hyper-tonia), restlessness, sleepingproblems, inconsolable crying, andreflex abnormalities. Heavy maternalalcohol use is also associated with adecreased ability among newborns totune out inappropriate stimuli, poorsucking abilities, and disturbed pat-terns of sleep and wakefulness.

More research is needed on theinteraction between drinking and cig-arette smoking. This combination ofdrug use has been found to reducethe responsiveness or newborn babieswhose mothers drank socially andsmoked moderately during preg-nancy. Even babies whose mothers

consume only one drink a day duringthe first 3 months of pregnancy havemore erratic sleeping patterns thaninfants of nondrinking mothers.

Since the beginning of the 18th cen-tury, physicians and researchers inEngland and France have observedand reported harmful effects ofmaternal alcohol consumption on off-spring. It was not until 1973, however,that a group of scientists at the Uni-versity of Washington, Seattle,labeled a characteristic pattern ofsevere birth defects as "fetal alcoholsyndrome" (FAS). Numerous casesof this syndrome from all over theworld have now been reported Aconference of research specialists in1980 outlined standards for FAS diag-nostic criteria, which require at leastone feature from each of threecategories:

1. Prenatal and postnatal growthretar lation with abnormallysmal.-for-age weight, length,and/or head circumference

2. Central nervous system disor-ders with signs of abnormalbrain functioning, delays inbehavioral development, and/orintellectual impairment

3. At least two of the followingabnormal craniofacial fea-tures small head, small eyesor short eye openings, or apoorly developed philtrum (thegroove above the upper lip),

17


thin upper lip, short nose, orflattened midfacial area

Other abnormalities have alsobeen reported in conjunction withFAS, including crossed eyes (strabis-mus) and near-sightedness, malfor-mations of the ears, heart murmurs,liver and kidney problems, retardedbone growth and skeletal defects,increases in upper respiratory infec-tions and in middle ear infections(otitis media), undescended testicles,and hernias.

FAS is now the leading knowncause of mental retardation. Severalinvestigators have noted that thedegree of mental impairment amongFAS children correlates closely withthe severity of their craniofacial mal-formations and growth deficiencies.The cognitive functioning of FAS chil-dren with the most severe CNSinvolvement does not improve, evenwith remedial instruction.

It is not known exactly how oftenFAS births occur. Studies of popula-tion groups in the United States havemost consistently found rates rangingfrom 1 to 3 cases per 1,000 live births.European cities that have been stud-ied have comparable rates, averaging1 case per 650 live births. However,among one American Indian popula-tion at particularly high risk for alco-holism, a rate of 9.8 cases per 1,000births was observed.

Not all alcoholic women whobecome pregnant deliver babies with

FAS. In one study of contributoryrisk factors, an FAS diagnosis wasmost frequently associated with themother's persistent drinking through-out pregnancy, a greater number ofalcohol-related problems (measuredon the Michigan Alcohol ScreeningTest MAST), a larger number ofprevious births, and being Black.Women with all four characteristics

an 85-percent chance of produc-ing a baby with FAS. In contrast,women with none of these risk fac-tors had only a 2-percent probability

Binge drinking of more than fivedrinks on any occasion anddrinking during the first 2 monthsof pregnancy are two of thestrongest maternal predictors oflater neurobehavioral deficitsamong offspring.

for an FAS baby. In another high-riskgroup, 1 in 4 mothers who hadalready had an alcohol-affected childgave birth to other FAS-diagnosedchildren. In more recent work, drink-ing an average of three drinks perday during the period following con-ception and before pregnancy wasconfirmed (organogenesis phase) wasthe threshold at which risk increasedfor the characteristic craniofacialanomalies in newborns that are usedto diagnose FAS. However, taking an

18


occasional drink during the earliestweeks of pregnancy did not increaserisk for these alcohol-associated ana-tomical defects.

Prenatally alcohol-exposed babie swith birth defects that do not meet allthree criteria for an FAS diagnosismay be categorized as having sus-pected "fetal alcohol effects" (FAE).These adverse consequences ofmaternal alcohol use usually includegrowth retardation and are estimatedto be about 3 times more frequentthan FAS. One perinatal specialistestimates that as many as 5 percent ofall birth defects may be attributableto prenatal alcohol exposure.

Effects on breastfeeding: Alcoholreaches the same concentration inmother's breast milk as in blood andis rapidly transmitted to the nursinginfant. Because milk consumed bythe baby is diluted with body water,the infant's blood alcohol content(BAC) will ordinarily remain muchlower than the mother's. A singledrink by a breastfeeding mother isprobably not much cause for alarm,but chronic exposure of the nursinginfant to high doses of alcohol ispotentially dangerous. A baby oxi-dizes alcohol more slowly than anadult.

Heavy drinking by the mother candecrease her milk supply, as well asinhibit the milk-ejection reflex. Nurs-ing babies whose mothers regularlyconsume alcohol may be irritable,

drowsy, and have abnormal weightgain. Animal and human researchalso indicates that newborn infantsexposed to alcohol before birth haveweaker sucking responses than thoseborn to nondrinking mothers.Although the decision to brcastfeedentails complex risk-benefit issues,the safest recommendation is thatwomen not consume alcohol whennursing.

Effects on the growing child: Theneurobehavioral effects of prenatalalcohol exposure reflect a spectrumof dose-dependent gradations, rang-ing from gross retardation to subtleCNS deficits. Although neurobehavio-ral effects are produced at lower lev-els of maternal drinking than grossphysical malformations and growthdeficiencies, they may be more devas-tating to youngsters in the long run.Binge drinking of more than fivedrinks on any occasion and drinkingduring the first 2 months of preg-nancy arc two of the strongest mater-nal predictors of later neuro-behavioral deficits among offspring.

Children whose mothers drankheavily during pregnancy may exhibitdevelopmental problems such ashyperactivity, distractibility, shortattention spans, language difficulties,and delayed maturation, even whentheir.intelligence is normal.

FAS-diagnosed children continueto show poor muscle tone, poor con-trol of their body movements, and

19

Hazards of Pr ital Exposure to Alcohol, Tobacco, and Other Drugs

delayed mental development. Evenwith proper nourishment, these chil-dren do not catch up to normal chil-dren in their physical growth. Theyalso have decreased attention spansand delayed reaction times.

Although neurobehavioral effectsare produced at lower levels of

maternal drinking than grossphysical malformations and growthdeficiencies, they may be moredevastating to youngsters in thelong run.

In studies tracking the develop-ment of children born to light andmoderate drinkers, researchers havealso correlated their mothers' drink-ing patterns during pregnancy withdecreased attention spans anddelayed reaction times in the off-spring, and with IQ scores at age 4years. Youngsters whose mothersaveraged three drinks per day duringpregnancy were likely to have IQsaveraging five points lower than nor-mal. However, fewer than 1 in 5 ofthe 4-year-olds in this study whosemothers consumed an average of fourdrinks per day while pregnant weredetermined to be clinically abnormalafter extensive examinations.

Ten years after the first 11 FASinfants were described, 8 werelocated and reexamined. All werestill below average in height and in

head circumferences, and four wereseverely retarded, with IQs between20 and 57. In addition, new physicalproblems were found: chronic middleear infections together with somehearing loss, poor alignment of theteeth, and vision problems. Only twoof the children were living with theirnatural mothers. Three of the moth-ers died of alcoholism before theirchildren were 6 years old.

More recently, one of the Seattlescientists reported that impairmentsin intelligence and academic achieve-ment resulting from alcohol-relatedbirth defects (FAS/FAE) continueinto adolescence and young adult-hood. Arithmetic skills seem to bemore seriously affected than readingand spelling abilities. The psychoso-cial problems of many FAS/FAE ado-lescents may also stem from in uteroalcohol exposure. The worst behav-ioral outcomes, however, probablyreflect a combination of prenatallyinduced brain damage and childrear-ing in a high-risk environment of par-ental alcoholism. Some clinicians areencouraging about the potentialreversibility of some behavioralabnormalities in alcohol-exposed chil-dren as they mature and participatein remedial programs.

Tobacco

Nicotine, the psychoactive ingredi-ent in cigarettes, is an addictive,biphasic drug that can both stimulate

20


and relax the user. Tobacco smokealso contains many other toxic ingre-dients, including carbon monoxide,nitrous oxide, lead, hydrogen cya-nide, and 43 known carcinogens.

Cigarette smoking is the major sin-gle and preventable cause of diseaseand premature death in the UnitedStates. Smoking is a cause of coro-nary heart disease, stroke, chronicobstructive pulmonary disease, can-cers of the lung, mouth, larynx, andesophagus, and other circulatory dis-ease Women cigarette smokers whoalso take oral contraceptives are atdramatically increased risk for heartattacks (myocardial infarctions) andstrokes (subarachnoid hemorrhages).The risk is dose related.

Despite growing public concernabout smoking, public policies to dis-courage tobacco use, and an overallreduction in smoking among Ameri-can adults, smoking among womenhas declined much more slowly thanamong men. Decreases in smokinginitiation rates among young women,particularly those with less education,did not keep pace with decliningrates for males in the years between1965 and 1985. For more than adecade, more adolescent girls thanboys in their senior of high schoolhave reported being daily cigarettesmokers. Quitting smoking is also dif-ficult: relapse rates are comparableto those for alcoholics and heroinaddicts. Approximately two out ofthree users who stop taking any one

of these drugs resume use by the endof a year.

Suspected mechanisms of drug dam-age to the fetus: While nicotinecrosses the placenta, its harmfuleffects are primarily the result ofblood vessel constriction in themother and the consequent reducedoxygen supply to the fetus. This oxy-gen reduction (hypoxia) is alsoincreased by carbon monoxide inter-fering with the blood's ability to dis-tribute oxygen throughout the body.

Effects on fertility: Fertility is oftenimpaired in men and women whosmoke. Several large-scale studieshave found higher infertility amongsmoking than nonsmoking women. A1985 study found that women smok-ers were 3.4 times more likely thannonsmokers to take a year or longerto conceive a desired child. Womenwho smoked more than a pack and ahalf of cigarettes a day had a 43-per-cent lower fertility rate than non-smokers. Women who smokeregularly are also more likely thannonsmokers to have menstrual irregu-larities and amenorrhea (cessation ofmenses). Among men who smoke,the secretion of male hormones isreduced, sperm production andmobility arc lowered, and moresperm are abnormally formed. Theseeffects can cause male infertility,especially among those who are onlymarginally fertile.

21


Effects during pregnancy and deliv-ery: There is a direct correlationbetween the amount of smoking dur-ing pregnancy and the frequency ofspontaneous abortion and fetaldeath. Pregnant women who smokealso have significant increases in pre-mature detachment of the placenta(abruptio placentae), vaginal bleed-ing, abnormalities in placenta attach-ment to the uterus (placenta previa),ruptured membranes, and pretermdelivery. All these complications ofpregnancy carry a high risk of perina-tal loss.

Maternal smoking has beenimplicated in as many as 14 percentof preterm deliveries in the UnitedStates. Prematurity increases therisks for early infant death and forrespiratory illness. A recent large-scale study of over 30,000 pregnantwomen in Northern California foundthat preterm births were 20 percentmore common among women whosmoked a pack a day or more duringpregnancy when compared tononsmokers.

Effects on the newborn: There areconflicting findings regarding an asso-ciation between smoking and somecongenital malformations (most usu-ally heart defects, cleft palate, her-nias, and central nervous systemabnormalities). This lack of a consis-tent pattern has led some researchersto conclude that maternal (or pater-nal) cigarette smoking is probably

not the sole cause for these abnormal-ities. However, recent large-scalestudies confirm a positive associationbetween physical defects among new-borns and maternal smoking duringpregnancy. There are higher rates ofabnormalities in a variety of catego-ries for children born to smokersthan to nonsmokers.

Women who smoke during preg-nancy have babies that are, on aver-age, 7 ounces (200 grams) lighterthan those born to comparable non-smoking women. Reductions ininfants' birthweight are proportionalto the amounts mothers smoke andare independent of other risk factorsand gestational age. The earlier inpregnancy that a woman stops smok-ing, the better her chances for deliver-ing a normal-weight baby. Based on anationwide study, if all womenstopped smoking during pregnancy,the frequency of low birthweightinfants would decrease by amountsranging from 35 percent among moth-ers with less than a high school educa-tion to 11 percent among those bornto college graduates. These lowbirthweight babies are also shorterthan normal for their gestational ageand have smaller head and chest cir-cumferences. Long-term studies, stillin progress, provide no indicationthat these growth-retarded childrencatch up in later years.

Passive smokingbeing exposedto the smoking of others hasrecently been indicted for having

22


harmful effects on pregnancy. Astudy of 500 Danish women foundthat pregnant nonsmokers married tosmoking husbands consistently hadlower birthweight babies than thosemarried to nonsmokers. The infants'weight reduction was only about athird less than if the mothers them-selves smoked. Another study ofmore than 900 nonsmoking Americanwomen passively exposed to cigarettesmoke during pregnancy found thatthey had twice the risk of delivering alow birthweight baby compared tomothers not similarly exposed. Athird study of over 1,200 nonsmokingwomen, whose passive smoke inhala-tion during pregnancy was confirmedby blood tests, also found that theygave birth to consistently lowerbirthweight infants than those notexposed to tobacco smoke.

Three studies found low Apgarscores among babies born to smokingmothers. (Apgar scores evaluate thebasic health of newborns at 1- and 5-minute intervals after birth by mea-sures of heart rate, respiration,reflexes, muscle tone, and skin color.)One study involving 43,000 babiesreported low scores occurring 4 timesas often among the newborns ofmothers who smoked 2 to 3 packs ofcigarettes per day than amongnonsmokers' babies However, a largeBoston City Hospital study did notconfirm this association when otherconfounding risk factors werecontrolled.

Infants born to mothers whosmoke are at a higher risk of dyingbefore their first birthdays. This riskis related to the amount smoked. Arecent 4-year study of infant mortalityfound that women who smoked apack a day or more had a 56-percenthigher rate of infant death amongtheir firstborns than nonsmokers.Firstborn babies of mothers whosmoked less than a pack a day werestill 25 percent more likely to diewithin the year than nonsmokers' firstoffspring. Smoking by mothers,regardless of the amount, increasedthe rate of infant deaths among laterchildren by 30 percent. This increasein infant deaths is primarily due torespiratory difficulties and suddeninfant death syndrome (SIDS) theleading cause of death in babies dur-ing their first year.

Effects on breastfeeding: Nicotine istransmitted in breast milk and seemsto inhibit milk production, as well asto reduce the level of vitamin Cfound in breast milk. Women whosmoke are less likely to breastfeedtheir infants than nonsmoking moth-ers and, if they do begin nursing afterdelivery, to switch to bottle feedingtheir babies soon after leaving thehospital.

Effects on the growing child: Chil-dren of mothers who smoke whilepregnant are more likely to haveimpaired intellectual and physical

23


growth. Maternal smoking has alsobeen associated with such behavioralproblems in offspring as lack of self-control, irritability, hyperactivity, anddisinterest. Long-term studies indi-cate that these children perform lesswell than matched youngsters of non-smokers on tests of cognitive, psycho-motor, language, and generalacademic functioning. However,these differences are small when com-pared to other factors affectingachievement in these areas.

A recent critical review of thesestudies now questions whether thereis a causal relationship betweenmaternal smoking during pregnancyand deficits in growth, cognitivedevelopment, educational achieve-ment, attention span, and hyperactivebehavior among offspring. Potentiallyconfounding differences between par-ents who smoke and nonsmokers inpsychological factors and family con-text of the childrearing environmentwere not sufficiently controlled in ear-lier research to attribute differencessolely to tobacco's toxic effects.

Maternal smoking does increase achild's chances for developing colds,asthma, and other respiratory prob-lems, although it is not clear whetherthese effects are from fetal exposureto nicotine or from passive inhalationof household smoke after birth. Evi-dence from both human and animalstudies suggests that in utero expo-sure to nicotine adversely affects fetallung development. Still, young babies

NNW

living in homes where both parentssmoke are more often hospitalizedfor pneumonia or bronchitis than arebabies whose parents don't smoke.They are also at increased risk formiddle ear infections.

Marijuana

Marijuana consists of the driedparts (flowers, seeds, leaves, andstems) of the Indian hemp plant, Can-nabis sativa. The drug is usuallysmoked in cigarettes, pipes, or waterpipes for its intoxicating and sensory-distorting "high," although it can bemixed into food and eaten. Themajor psychoactive ingredient isdelta-9-tetrahydrocannabinol (THC),but other components are biologi-cally active, and additional additivesor contaminants may be present. Con-centrations of THC in legally confis-cated marij na have risen fromaround 1 to 2 percent in the 1970s toan average of 3 to 5 percent cur-rently. The potency varies widelyaccording to source, ranging as highas 18 percent. This variability inpotency and chemical content of mar-ijuana, as well as in use patterns,makes findings from differentresearch studies particularly difficultto compare.

The smoke from marijuana sharesmany characteristics with tobaccosmoke and presents similar dangers.A comparison of the tars from bothdrugs has shown that, when smoked

24


the same way, marijuana producesmore than twice as much tar as a pop-ular American cigarette and, wheninhaled deeply and exhaled slowlyas is usual in smoking this drugyields nearly 4 times more tar.Inflammation and other abnormali-ties in the lungs of marijuana smokershave led to warnings that heavy usersare at risk for chronic asthma, bron-chitis, or emphysema. Marijuanaintoxication reduces menial effi-ciency, especially for complexthinking.

Marijuana is a widely known, thor-oughly studied, and very old drug.American medical literature on thisdrug dates back to 1843 and containsmore than 5,000 titles. Yet objectiveand consistent findings about thehealth consequences of use, particu-larly for pregnant women and theiroffspring, are still sparse. Althoughpregnant women are less likely to usemarijuana than alcohol or cigarettes,heavy marijuana users are less likelyto reduce their marijuana consump-tion during and after pregnancy thanto cut back on drinking and smoking.

Suspected mechanisms for drug dam-age to the fetus: Marijuana readilycrosses the placenta, although trans-fer is apparently higher in early preg-nancy than in the last trimester. Thedrug level in the bloodstream of themarijuana-smoking mother is gener-ally greater than that of the fetus,ranging from 2.5 to 7 times higher.

Like cigarettes, marijuana increasescarbon monoxide levels in themother's blood that can reduce oxy-gen in fetal blood.

Effects on fertility: Chronic mari-juana use can lower sperm counts inmales and may affect menstrualcycles and ovulation in females.These effects appear reversible whenuse stops and, in females, when toler-ance is established. Temporary steril-ity may sometimes result, however,when couples are marginally fertile.In laboratory animals, marijuana alsoinhibits the secretion of reproductivehormones, interfering with ovulationin females and sperm production inmales. As with humans, hormone lev-els return to normal as tolerancedevelops to chronic exposure.

Despite earlier speculation andwarnings of potential genetic dam-age, no evidence of chromosomedamage to cells incubated with THChas been found in either animals orhumans.

Effects during pregnancy and deliv-ery: Animal studies suggest that mari-juana may cause spontaneous abor-tions and stillbirths, though only atmuch higher doses than those usedby most drug abusers. Laboratorystudies also suggest that animal moth-ers receiving THC produce moremale than female babies. One humanstudy had similar findings: the male-to-female sex-ratio of offspring

25


increased if either parent was a heavymarijuana smoke:.

Because the research findingsregarding marijuana effects onhuman pregnancy are inconsistent,caution is advised in ascribingadverse outcomes to the drug alone.In larger studies, where other mater-nal factors that might influence out-comes were controlled analytically,the drug did not consistently increasespontaneous abortions, stillbirths,and other interruptions of pregnancy.

Effects on the newborn:Increasedtremulousness, altered visualresponse patterns to a light stimulus,and some withdrawal-like crying havebeen noted in the newborn infants ofwomen who smoked marijuana heav-ily while pregnant. Although moresubtle long-term consequences can-not be ruled out, these effects usuallydisappear within 30 days. However, afollowup study by the same research-ers, using a larger sample, found per-sisting tremors and startles in the30-day-old offspring of mothers whoregularly used one or more marijuanajoints per week while pregnant.

Another 1988 study of neonatalsleep found that maternal marijuanause during pregnancy affected sleepand arousal patterns in the newborn.The long-range implications of thisfinding are not known.

In studying the relation betweenfetal marijuana exposure and low-ered birthweight or length and short-

ened gestation, only six studies exam-ined sufficient numbers of subjects tocontrol for such potentially compli-cating analytic factors as maternalsmoking, drinking, other drug use,and race/ethnicity. Unfortunately, thecollective findings from these studiesare conflicting and difficult to inter-

Chronic marijuana use can lowersperm counts in men and mayaffect menstrual cycles andovulation in women. These effectsappear reversible when use stops.

01.1011111.101111

pret. Unlike the research on tobaccosmoking, marijuana use during preg-nancy is not consistently associatedwith lowered birthweight, althoughindividual studies have found somedose-related reductions in gestation,infant length, and birthweight.

In a thoughtful discussion of thepossible reasons for these inconsis-tent results, one expert highlights(1) likely variations in the composi-tion of marijuana, (2) the problems inteasing out many other maternal fac-tors (health, socioeconomic back-ground, and lifestyle), and (3) othermethodological issues. A major con-cern is underreporting of marijuanause by pregnant women, compared toalcohol and cigarette use.

Most human evidence suggeststhat fetal marijuana exposure doesnot, by itself, produce physical abnor-

26r

t


malities. However, marijuana con-sumption by pregnant women, whencombined with other drug use, drink-ing, malnourishment, and inadequateprenatal care, may increase thechances of negative fetal conse-quences. A large Boston City Hospi-tal study found that maternalmarijuana use was the strongest pre-dictor of newborns with features com-patible with FAS. This findingsupports a possible synergistic effectof marijuana when interacting withalcohol and other substances.

Effects on breastfeeding: Marijuanais rapidly transmitted into breast milkand remains there for a prolongedperiod. Although its effects on nurs-ing infants are unknown, breastfeed-ing is not recommended for motherswho smoke marijuana and are unwill-ing or unable to give it up.

Effects on the growing child: Evi-dence of postnatal problems in chil-dren prenatally exposed to marijuanais both limited and inconsistent. Inone study, prenatally marijuana-exposed youngsters averaging 4 yearsof age were slower than matched con-trols in their visual responsiveness,indicating delayed maturation in thiscomponent of the central nervoussystem.

However, in an ongoing study ofbabies born to 700 women in Ottawa,Canada, the same researchers havenot found prenatal marijuana cxpo-

M1111111111111P

sure to be associated with diminishedmental, motor, or language outcomesor visual responsiveness in 1- and 2-year -olds. They are not certainwhether the apparent normality ofthese toddlers is due to the transitorynature of effects from prenatal mari-juana exposure or whether anyadverse effects are too subtle to bemeasured in early childhood, but maybe manifested by school age.

Cocaine

Cocaine hydrochloride, an extractof the coca plant, is a short-acting,powerful stimulant used medically asa local anesthetic. In low doses,cocaine produces a quick "lift" orsense of euphoria with increasedenergy, mental alertness, and sensoryawareness. Larger doses intensifyeffects, sometimes causing paranoidthinking that may result in bizarre orviolent behavior.

Among the most obvious signs ofchronic cocaine abuse are weight loss(because the drug suppresses appe-tite), irritability, and impaired sexualfunctioning. Cocaine use increasesblood pressure and heart rate andconstricts blood flow to body organs.Its continued use can damage theheart, increasing the risk for irregularheart rhythms and heart attacks. Athigh doses, cocaine can cause sei-zures and death. Combining cocainewith another drug may make it evenmore dangerous.

27

vi*


Until recently, many believed thatcocaine was not physically addict-ing would not cause withdrawalsymptoms when stopped suddenly.There is now good evidence thatcocaine can cause profound depen-dence. Its abrupt withdrawal ismarked by a strong craving for thedrug, tremors, muscle pain, changesin brain activity, eating disorders,sleep disturbances, and, sometimes,severe depression and paranoid reac-tions. Thoughts of suicide may occur.

Most users begin by "snorting" thedrug in powder form. Those whoinject a soluble form of cocaine orsmoke it as freebase get a moreintense euphoric reaction, known asthe rush. Injection of cocaine pro-duces effects in about 30 seconds thatlast for 30 minutes. Psychologicaldependence on cocaine can occurvery rapidly. Although the cocaine"high" may be intensely pleasurable,it is quickly followed by a reactivecrash, with feelings of depression anddespondency. To escape these lows,heavy users tend to repeat the experi-ence, using cocaine in runs, doseafter dose, until their supply isexhausted.

Crack is the street name for a formof smokable, rapidly acting freebasecocaine, processed into crystals(rocks) and increasingly available atlow cost. Use of crack, especiallyamong urban youth, has grown alarm-ingly since its introduction in theearly 1980s. Smoked crack is 10 to 20

times more potent than powderedcocaine and more likely to result indeperdence. Crack and freebasecocaine smokers also tend to usemore of the drug than those whoinject or snort it.

In a study of 108 cocaine-usingmothers, birth outcomes improvedfor the women who stopped theirdrug use by the end of the first 3months of pregnancy.

'...........

Cocaine and crack are growingnational problems. Drug-relatedemergency room visits, overdosedeaths, and admissions to treatmentprograms for cocaine use continue toincrease at a faster rate than for anyother abused drug. Also, the purity ofstreet cocaine escalated from an aver-age of 29 percent in 1982 to 73 per-cent in 1984.

Another frightening aspect ofcocaine use is its frequent combina-tion with other drugs. Heavy cocaineusers may turn to heroin, alcohol, orother sedatives to alleviate with-drawal effects. Surveys of aduictsthe streets of major cities show agrowing preference for speedball-ing injecting a mixture of cocaineand heroin.

Women's attraction to cocaine andcrack is of particular concern. Inject-ing cocaine (or other drugs) poses

28

Z.)


special dangers of infection with thehuman immunodeficiency virus(HIV) that causes AIDS. Sharingneedles and other injection parapher-nalia (works) carrying HIV-infectedblood is a primary mechanism forAIDS-virus transmission. Not only isunsterilized equipment more likely tobe shared when drugs impair judg-ment, but women are very likely toshare needles with sexual partnerswho assist them in shooting up. Inmany inner cities, the escalating useof crack has also resulted in increas-ing numbers of women exchangingsex for drugs.

Both needle sharing and unpro-tected sex with HIV-infected part-ners have increased the frequency ofAIDS among women and amongtheir offspring. Nearly 3 of every 4cases of AIDS reported in women(73 percent) is directly or indirectlylinked to intravenous drug use, and 4of every 5 youngsters (under 13 yearsold) with AIDS has a parent whoinjects drugs. Evidence suggests thatfrom 30 to 50 percent of prenatallyexposed babies of HIV-infectedmothers are also infected with thevirus. It takes as long as 15 monthsafter delivery to confirm whetherbabies' antibodies reflect their ownor their mother's infection. The exactmechanisms and timing of mother-to-child viral transmission are not com-pletely established, but prenatalexposure, delivery, and brcastfeedingare implicated.

In addition to increasing risks forAIDS, the sexual promiscuity associ-ated with crack cocaine use has beenblamed for growing numbers ofwomen with other sexually transmit-ted diseases (STDs). Although moretreatable than AIDS or HIV infec-tion, these infections can also betransmitted to the fetus or to theinfant at birth. The Centers for Dis-ease Control reports that the currentepidemic of syphilis among adultsand newborns in many inner cities isstrongly linked to cocaine and crackuse.

Suspected mechanisms for drug dam-age to the fetus: Cocaine crosses theplacenta and reaches the fetus, but itsdangers probably reflect actions onthe cardiovascular systems of themother and the fetus rather thanmore direct toxicity. Cocaine con-stricts the user's blood vessels, rcduc-ing blood flow through the placentato the fetus and diminishing both theoxygen supply and the nutrientsreaching the fetus. The vasoconstric-tive properties of the drug alsointerfere with normal placental func-tioning and may damage this fetal life-support system. Recent animalresearch experiments confirm theseeffects.

Because cocaine is a short-actingdrug, with doses repeated at frequentintervals, fetal blood flow reductionsdue to blood vessel constriction inthe mother arc likely to be intermit-

29 f`

O


tent and potentially disruptive to nor-mal development of fetal tissue. Thismechanism would be consistent withrecent reports of structural centralnervous system abnormalities, intesti-nal anomalies, and malformations ofextremities, as well as urogenital mal-formations in cocaine-exposedbabies. This pathogenic model wouldalso account for differences betweenmalformations observed amongcocaine-exposed and FAS-diagnosedbabies whose abnormalities reflectimpaired body and organ formationduring early pregnancy.

Effects during pregnancy and deliv-ery: The earliest reports of cocaineeffects on pregnancy noted a highrate of spontaneous abortion andearly separation of the placenta fromthe wall of the uterus (abruptio pla-centae). The complication of abrup-tio placentae has now beenconfirmed in at least five additionalstudies. In one study of in uterococaine exposure, abruptio placentaewas also associated with an increasednumber of stillbirths.

Prenatal cocaine use is also associ-ated with an increased rate of prema-ture rupture of membranes, earlyonset of labor, and preterm delivery.Cocaine apparently causes contrac-tions of the uterus and, according toone neonatologist, "It is commonknowledge in the streets that crackwill induce labor." Some women haveused the drug in attempting self-

induced abortions. Premature laboris most likely to occur if cocaine istaken during the last 3 months ofpregnancy. Pregnant mothers shouldbe warned that cocaine use within afew days of delivery can be especiallyhazardous.

At least one study indicates thatcocaine use during pregnancy may bemore harmful to expectant motherand their newborns than other drug,A study of 239 women in Philadel-phia found that women who usedcocaine during pregnancy had thepoorest maternal and infant healthoutcomes when compared to eithernon-drug users or to womendependent on other drugs but notcocaine.

In another study of 108 cocaine-using mothers, birth outcomesimproved, for the women whostopped their drug use by the end ofthe first 3 months of pregnancy.More of their pregnancies lasted 9months, and they delivered more nor-mal-weight babies than the motherswho continued using cocaine. Infantsborn to mothers who stopped usingcocaine before the last trimester ofpregnancy also had improved intra-uterine growth compared to babiesexposed to cocaine throughout theirin utero development. The rate ofearly placental separations did notdecrease, however, even whencocaine use stopped early in the preg-nancy. The damage to the placentaland uterine blood vessels that results

30


from cocaine use in early pregnancyis apparently nonreversible.

Effects on the newborn: Cocaine useduring pregnancy is most consistentlyassociated with increased risk amongnewborns for intrauterine growthretardation (IUGR). This finding hasnow been confirmed by several differ-ent researchers. The largest studyexamined 1,226 primarily low-income, minority women receivingprenatal care in Boston and foundthat 114 babies born to mothers withpositive urine assays for cocaine hadsignificantly lower birthweight andlength and suialler head circumfer-ences than newborns of drug-freecontrols. The researchers noted thatappetite-suppressing characteristicsof cocaine are related to poor mater-nal nutrition, which may also contrib-ute to lowered birthweight inprenatally exposed infants.

The recent dramatic increase incrack cocaine use led a New Yorkresearch team to compare maternaland infant outcomes for 55 minoritywomen who had smoked crack dur-ing pregnancy with 55 non-drug-usingpregnant women, matched on otherhealth and lifestyle factors. Over halfof the crack users delivered prema-turely (50.9 percent versus 16.4 per-cent of nonusers). Their newborninfants were over 3.5 times morelikely to be growth retarded andnearly 3 times more likely to have areduced head circumference.

Babies born to cocaine-using moth-ers appear to have fewer clearly dis-cernible withdrawal symptoms thanbabies exposed to heroin and othernarcotics in utero. Although thecocaine-exposed newborns tend to bejittery, to cry shrilly, and to startle ateven the slightest stimulation, theseeffects have generally been attributedto neurobehavioral abnormalitiesrather than withdrawal. In a compari-son of 104 infants born to motherswho had used cocaine, methamphet-amine (speed), heroin, and/ormethadone during pregnancy, thenewborns prenatally exposed tococaine and/or methamphetaminedisplayed such altered behavior pat-terns as abnormal sleep, poor feed-ing, tremors, and increased muscletone. The investigators concludedthat these behaviors representeddirect effects of the drugs, not with-drawal.

Another study of cocaine-exposedinfants found signs of central nervoussystem irritability in 34 of 39 new-borns. Although the EEGs (electro-encephalograms or brain wavetracings) were abnormal in 17 ofthese babies during their first week oflife, these patterns appeared to betransient and became normal beforethe babies were a year old.

Neurological abnormalities amongcocaine-exposed newborns, such asimpaired ability to orient and to con-trol muscles, have also been mea-sured on the Brazelton Neonatal

31


Behavioral Assessment Scale. Thisset of tests measures newborns' func-tioning abilities: how well their eyesreact to light, how well they respondto people or to the environment, howquickly they stop reacting to selectedvisual and auditory stimulation, howwell they can use their muscles, andhow well body temperature is regu-lated. Persisting abnormalities of

Several studies have suggested anassociation between in uterococaine exposure and structure:birth defects, notably of thegenitourina: y tract, cardiovascularsystem, central nervous system,and extremities.

muscle tone, reflexes, and volitionalmovement were also found in 43 per-cent of otherwise healthy 4-month-old cocaine-exposed babies, using aset of tests called the MovementAssessment of Infants (MAI). Somemuscle tone and movement problemswere still apparent when these babieswere retested at 8 months. Suchmovement-related problems in new-borns are generally associated withdelays or deficits in motordevelopment.

One investigation of newborns pre-natally exposed to cocaine found anincreased risk for SIDS, but subse-quent and larger prospective studiesfailed to confirm this.

Several studies have suggested anassociatien between in utero cocaineexposure and structural birth defects,notably of the genitourinary tract, car-diovascular system, central nervoussystem, and extremities. Cases havealso been reported of cerebral infarc-tions, CNS lesions, and neural tubedefects among cocaine-exposedbabies. However, although sufficientdata for definitive conclusions haveyet to be collected in large-scale andwell-controlled studies, the risk formajor malformations does notappear to be greatly increased amongcocaine-exposed babies.

A critical review of 14 recent clini-cal studies on fetal effects of mater-nal cocaine use found a total of just260 infant research subjects whowere prenatally exposed only tococaine and no other illicit drugs.After analyzing the findings to date,this author concludes that prenatalcocaine exposure is most clearly arisk factor for decreased birthweightand small-for-gestational-age babiesand is frequently associated withabruptio placenta and prematurebirth.

Conclusions about increased riskfor structural anomalies are still pre-mature, but preliminary data from alarge CDC study of birth defects (aswell as findings from earlier studies)indicate that defects in the genitaliaand urinary tract may, indeed, bemore prevalent among cocaine-exposed babies. Continuing reports

32

f


of very serious central nervous systemmalformations, limb anomalies, intes-tinal impairments, and facial abnor-malities are disturbing, but requirefurther confirmation. In uterococaine exposure is apparently associ-ated with behavioral abnormalitiesamong newborns. All of thesecocaine-related risks, however, areultimately so interwoven and con-founded by other maternal risk fac-tors that the absolute risk of maternalcocaine use may never beascertained.

Effects on breastfeeding: Cocaine useby nursing mothers may also pose athreat to their infants. Two casereports illustrate this. In one, markedtremulousness, irritability, startleresponses, and other neurologicalabnormalities in a 2-week-old infantgirl were traced to cocaine in hermother's milk. The infant's urine stillcontained a byproduct of cocaine 60hours after last being breastfed byher cocaine-using mother. A morerecent report describes convulsionsin an 11-day-old nursing infant, result-ing from the mother's use of cocaineon her nipples to relieve soreness.

Effects on the growing child: It is tooearly to know whether the neuro-behavioral effects identified incocaine-exposed newborns continueinto later childhood and adult life.Very few studies with large popula-

tion samples have been completed;more are needed.

Heroin andOther Opioids orSynthetic Narcotics

Opioids arc natural and syntheticdrugs that primarily act on the cen-tral nervous system. Classified as nar-cotics, this group of drugs includesthe illicit substance, heroin, as well assuch well-known therapeutic medica-tions as morphine, codeine, meperid-inc (Demerol), oxcycodone(Percodon), hydromorphone(Dilaudid), pentazocine (Taiwin),and methadone (used in the treat-ment of heroin and other opioiddependence). Opium, heroin, andmorphine arc all derived from thejuice of the opium poppy plant.

Like cocaine, heroin in differentforms can be inhaled (snorted) orsmoked, but is most frequentlyinjected under the skin or into a vein(mainlining). The various syntheticsusually come in pill or tablet form,but they can also be dissolved andinjected. In general, opioids andrelated synthetic drugs relieve painand cause drowsiness, mood fluctua-tions, brain activity changes,depressed breathing, and slow diges-tive functioning. Nausea and vomitingare common after initial use; consti-pation often accompanies regularuse.

33


Chronic users describe psychologi-cal reactions in terms of a euphoric"high," followed by mellow "nod-ding," before withdrawal effectsbegin. As tolerance develops to thedesired psychoactive effects, largerand larger doses are needed to pro-duce the same "high" feelings. Con-tinuous use of opioid drugs, even forrelatively short periods of time,causes physical dependence. Oncephysically addicted, abrupt cessationof opioid use results in withdrawalsymptoms (also called abstinenceeffects).

Pregnancy complications for heroinaddicts include increased risk ofabruptio placentae, eclampsia,placental insufficiency, breechpresentations, premature labor andruptured membranes, andCaesarean sections. From 10 to 15percent of these women developtoxemia during pregnancy thatmay lead to eclampsia.

If untreated, typical flu-like opioidwithdrawal symptoms include chills,gooseflesh, tears, runny nose, yawn-ing, rapid heart rate, high blood pres-sure, perspiration, irritability,cramping, diarrhea, insomnia, andmuscle spasms. For most heroinaddicts, the peak period of discom-fort is 48 to 72 hours after the last

drug dose. Without treatment, visiblesymptoms of withdrawal continue for7 to 10 days, but it may take weeksfor the body to return to normal func-tioning. Although uncomfortable, her-oin withdrawal, unlike that fromhigh-dose, chronic alcohol or barbitu-rate dependence, is seldom lifethreatening. Craving for heroin orother narcotics is often described bychronic users long after the body hasreturned to normal. Relapse is com-mon among heroin users, as it isamong chronic abusers of tobacco,alcohol, and cocaine.

The most hazardous overdose reac-tions to large amounts of narcoticsrange from breathing difficulties tocoma and possible death, caused bysuppression of the brain center thatregulates respiration. Major medicalproblems associated with heroinaddiction are caused by the additivesused to cut heroin before street salesand by infections transmitted inunsterile paraphernalia used forinjection. The risk for infection withthe virus that causes AIDS is greatlyincreased among narcotics abuserswho inject drugs and share unsterile"works. "

In treating heroin addiction,another narcotic, methadone, issometimes substituted for the illicitdrug. Under medical supervision, themethadone dosage may be slowlyreduced to prevent the unpleasanteffects of cold-turkey withdrawal asthe user detoxifies. Alternatively, the

34


methadone dosage may be main-tained at a comfortable level, fore-stalling withdrawal until the addictedindividual has made other lifestylechanges and is better prepared tobecome and remain drug free.

The extent of heroin use and abuseamong women is unknown. Treat-ment programs generally serve moremen than women, although federallyfunded programs report an increasein the proportion of female clients (to30 percent) in recent years, especiallyas more appropriate services areprovided.

Studies of narcotic-addictedwomen find numerous health and psy-chosocial problems that must bedealt with during treatment andrecovery. Women entering drug treat-ment usually have more medical prob-lems than male addicts, includinganemia, STDs, hepatitis, hyperten-sion, urinary tract and other infec-tions, and diabetes. Most come fromlow socioeconomic backgrounds andare undereducated and unskilled.Many are involved in prostitution atsome point and also have criminal his-tories, with petty charges for shoplift-ing and other drug-related activities.Most suffer from low self-esteem anddepression. The majority are of child-bearing age and already have chil-dren, although their parenting skillsmay be limited, and child neglect andabuse are not uncommon. The life-styles of heroin-abusing women arctypically chaotic.

The many complications of heroinaddiction cause additional concernsregarding mothering and other risksto offspring. Injection of drugs by themother or her sexual partner is asso-ciated with 4 in every 5 pediatricAIDS cases. The STDs found infemale addicts also threaten theirbabies. Bacterial endocarditis, a life-threatening infection of the heart'slining associated with intravenousdrug use, is an added risk for preg-nant addicts and their offspring. Arecently published case study ofseven pregnant women with bacterialendocarditis reported that two ofthem died shortly after giving birth.Two of the newborns also died as aresult of preterm delivery, which mayhave been related to the disease.

Suspected mechanisms of drugeffects on the fetus: It has long beenknown that opioid drugs taken by themother reach the fetus. But it onlybecame clear about 18 years ago thatnewborn babies suffer withdrawalsymptoms if their mothers arechronic heroin users. More recentstudies have confirmed that opioidscross the placenta and enter the fetalbloodstream, but the level of eitherheroin or methadone in the fetusremains lower than in the mother. Apregnant woman's use of narcoticsmay reduce the oxygen supply to thefetus (hypoxia). Alternating toxic andwithdrawal effects experienced by themother also result in an unstable uter-

35


inc environment. In addition, heroinand other narcotics suppress mater-nal appetite and may interfere withthe absorption of nutrients fromfoods by reducing intestinal, liver,and pancreatic functioning.

Efforts to explain the long-termeffects of prenatal opioid exposurehave primarily focused on fetal braingrowth. Animal studies have foundreductions in the number of braincells, alterations in brain ribonucleicacid (RNA) and protein content,reductions in the thickness of thecerebral cortex (the outermost layersof brain tissue), retarded develop-ment of biochemical systems thatcarry nerve impulses, and retardedgrowth of cells affected by with-drawal of opioid drugs. This researchis complicated by the fact that theprenatal human brain, like themature adult brain, contains opioid-like chemicals. One theory suggeststhat prenatal exposure to opioiddrugs retards fetal development byinterfering with the growth of braincells that are sensitive to opioids,both those produced naturally in thebody (called endorphins andenkephalins) and those taken asdrugs.

Effects on fertility: Opiate use bywomen increases amenorrhea (cessa-tion of menstrual periods) and men-strual irregularity, thereby interferingwith fertility. Many women who useheroin also report a decrease in sex-

ual desire. The STDs associated withprostitution and the lifestyles of manyheroin addicts often result in pelvicinflammatory disease (PID). Thiscondition causes scarring of the fallo-pian tubes and seriously impairsfertility.

Methadone-maintained women aremore likely to be fertile after a yearor more of treatment when toleranceis well established. However, preg-nancy among heroin addicts is notuncommon. Because of menstrualirregularities, heroin-addictedwomen are likely to misinterpretsigns of early pregnancy, such as nau-sea and tiredness, as withdrawalsymptoms. This may delay their con-firming and accurately dating theirpregnancies.

Effects during pregnancy and deliv-ery: Pregnancy complications for her-oin addicts include increased risk ofabruptio placentae (early separationof the placenta), eclampsia (a seri-ous, sometimes fatal, toxic conditionwith high blood pressure, swelling,seizures, or coma), placental insuffi-ciency, breech presentations, prema-ture labor and ruptured membranes,and Caesarean sections. From 10 to15 percent of these women developtoxemia during pregnancy that maylead to eclampsia.

Heroin use during pregnancyincreases the likelihood of stillbirthsand fetal distress, indicated by meco-nium staining (excreting fecal matter

36


into the amniotic fluid) and aspira-tion pneumonia in the newborn.These effects are attributed to alter-nating toxic and withdrawal states inthe expectant mother. In addition,nearly half of heroin-dependentwomen who receive no prenatal caredeliver prematurely, often because ofinfections.

Effects on the newborn: A well-con-firmed risk to newborns frommothers' opioid use during preg-nancy is intrauterine growth retarda-tion (IUGR) and small size forgestational age. Birthweight inopioid-exposed infants may also berelated to the amount of prenatalcare their mothers received, as wellas to the specific narcotic used. A1977 study in Philadelphia found thatnearly half (47.6 percent) the infantsborn to 63 heroin-abusing womenwith no prenatal care were of lowbirthweight. This contrasted with lessthan a fifth (18.8 percent) of thebabies born to 135 methadone-main-tained mothers receiving good prena-tal care being of low birthweight.However, appropriate prenatal caredid not completely eliminate compli-cations among pregnant opiate-dependent women and theiroffspring when compared to a similargroup of nondrug-using women andinfants.

About 80 percent of babies born toheroin-addicted mothers have suchserious medical problems as hyaline

membrane disease (a serious lung dis-ease), brain hemorrhages, and respi-ratory distress syndrome. Themajority of these complications arethe result of prematurity. Infantsborn to heroin-using mothers are alsoat risk for perinatally transmittedHIV infection, later developing intoAIDS. Higher death rates amongthese newborns are attributed toSIDS, as well as to poor living condi-tions in which infections are morelikely and more dangerous to prema-ture and/or low birthweight infants.

Although opioid exposure beforebirth is not usually associated with anincreased risk for physical malforma-tions, 1 in 4 infants born to mothersin a methadone treatment programhad strabismus a visual disorder inwhich the infant's eyes cannot focustogether properly. This is a rate 5 to 8times higher than that in the generalpopulation. Since other psychoactivedrugs in addition to methadone wereused by the mothers during preg-nancy, these findings suggest thatmaternal drug abuse may predisposeinfants to strabismus and that clini-cians should evaluate drug-exposedinfants for visual abnormalities.

Dramatic withdrawal symptomsare the most frequently observed con-sequence to newborns from prenatalnarcotics exposure. This neonatalabstinence syndrome has beenobserved in hundreds of infants bornto opiate-addicted mothers. Restless-ness, tremulousness, disturbed sleep

37


and feeding, stuffy nose, vomiting,diarrhea, a high-pitched cry, fever,irregular breathing, or seizures usu-ally start within 48-72 hours. The her-oin-exposed ir.-ant also sneezes,twitches, hiccups, and weeps. Occa-sionally, these symptoms do not beginuntil 2 to 4 weeks after delivery. Thisirritability, resulting from overarousalof the central nervous system, usuallyends after a month, but can persistfor 3 months or more.

Between 60 and 90 percent of new-borns prenatally exposed to opioiddrugs develop abstinence signsrequiring special, gentle handling andmedication after birth. These difficultnewborns, like the jittery cocainebabies, are challenging to their care-takers. Their agitation may discour-age appropriate bonding with theirmothers unless appropriate parentingskills are taught and encouraged.Heroin-exposed newborns may alsohave poorly controlled responses totheir surroundings and difficultiesdirecting their attention to sights andsounds.

Effects on breastfeeding: Heroin,methadone, and other narcotics (e.g.,codeine, morphine) are transmittedin breast milk. Observers in the earlyyears of this century noted thatopium withdrawal symptoms in thenewborn could be alleviated bybreast milk from an addicted motherand that a breast-fed baby couldbecome opioid dependent from nurs-

ing. More recently, nursing babieswhose mothers regularly used propox-yphene (e.g., Darvon) andoxcycodone (e.g., Percodon) showedsigns of drowsiness and failure tothrive.

Breastfeeding by motivated moth-ers in well-supervised methadonetreatment programs should not auto-matically be ruled out, particularlyduring the first 6 to 8 weeks postpar-tum when the greatest immunologicand bonding benefits are likely toresult. Some research stud:es suggestthat the newborn would be exposedto very small amounts of prescribedmethadone in breast milk, especiallywhen compared to prenatal exposurelevels from the same dosage. Beforea methadone-maintained mother 1,encouraged to nurse, she should be(1) well controlled on a stable dos-age, (2) in good health, with ade-quate nutrition, (3) not infected withHIV, tuberculosis, or hepatitis B,and (4) not using alcohol and otherdrugs.

It is important to note that cases ofHIV transmission through breastmilk have been documented. Further-more, the amount of methadonetransmitted and consumed by thegrowing baby, if nursing continuesbeyond 3 to 6 months of age, maymake later breastfceding inadvisable.Close monitoring is needed of thenursing baby's responses and the lac-tating mother's potential for otherillicit drug use.

38

Hazards of Prenatal Exposure to Alcohol, Tobacco, and Other. Drugs

Effects on the growing child: Whenheroin-exposed babies are followedbeyond the withdrawal period, theirabilities to adapt to their surround-ings and to interact with their care-givers seem to improve. After amonth, only subtle differences can beobserved between most of thesebabies and infants not exposed to nar-cotics in utero. However, the develop-ment of muscle control may beuneven and motor coordination moreimpaired in children who experiencesevere neonatal withdrawal.

Follow-up studies of babies born toheroin-using or methadone-main-tained women have been particularlydifficult: (1) the mothers drop out ofthe studies and cannot be traced, (2)the babies grow up in very differenthome environments that make it diffi-cult to differentiate outcomes result-ing from drug exposure from thosestemming from caretaking variations(especially continuing drug abuse byparents, as well as the presence orabsence of the mother), and (3) themothers have very different lifestylesduring pregnancy that also effect out-comes in their infants.

Nonetheless, growth disturbancesand other behavioral effects such ashyperactivity, shortened attentionspans, temper tantrums, slowed psy-chomotor development, andimpaired visual motor functioninghave been noted in infants and olderchildren born to opiate-dependantmothers. Several studies have shown

problems in speech development.However, test scores measuring thesechildren's physical and psychologicaldevelopment are generally within thenormal range.

Many of the problems associatedwith prenatal exposure to heroin alsooccur after prenatal exposure tomethadone. The findings regardingprenatal effects of methadone, itshould be noted, are complicated bythe fact that methadone-dosed moth-ers are likely to continue using otherdrugs, including heroin. In general,babies born to methadone-main-tained women receiving adequate

The heroin-exposed babies, at 1year of age, tended to be impulsive,easily upset by frustration, and hadsleep disturbances and tempertantrums. Between 12 and 18months, they were clearlyhyperactive.

and consistent prenatal care thrivebetter and have fewer neurologicalcomplications than those whosemothers continue to use heroin or totake methadone in an uncontrolledmanner during pregnancy.

A long-term study comparedbabies of heroin-using, methadone-maintained, and drug-free mothersreceiving prenatal care at a Houston

39 ,

t


city-county hospital. The heroin-exposed babies, at 1 year of age,tended to be impulsive, easily upsetby frustration, and had sleep dis-turbances and temper tantrums.Between 12 and 18 months, they wereclearly hyperactive. The clinician inthis study observed that the earlyyears of heroin-exposed children arefilled with "turmoil and chaos." Afterstudying the school performance ofprenatally heroin-exposed youngstersbetween the ages of 6 and 11 years,this researcher noted that their mostdistinguishing characteristic, in con-trast to groups with drug-free ormethadone-maintained mothers, wasan early separation from biologicmothers. Only 8 percent of untreatedmothers, versus 50 percent of themethadone-treated mothers, still hadcontact with their children after 3years. Otherwise, there were moresimilarities than differences in off-spring of untreated addicts and thoseof matched women not from thisbackground.

Experts generally agree that chil-dren of addicts have numerousschool and behavioral problems,whether they arc born to drug-usingmothers or raised by drug-using care-takers. This finding has importantimplications for interventions to (1)improve the home surroundings anddaycare opportunities of drug-exposed youngsters and (2) enhancethe parenting skills of theircaretakers.

Phencyclidine

Phencyclidine or PCP is a syntheticdrug, known by a variety of names(peace pill, angel dust, hog) in differ-ent parts of the country. Initiallydeveloped as an anesthetic forhumans and later used for animals, itis no longer used for either purpose.PCP Cyst became popular for its psy-choactive effects in the early 1970s

A study of nine infants whose

mothers primarily used PCP

during pregnancy found these

newborns to he more emotionally

unstable and less consolable than

infants prenatally exposed to other

drug,.

but was rapidly abandoned by usersbecause of its unpredictable effects,including hostility, aggressiveness,and other bizarre behavior. Duringthe late 1980s, PCP resurfacedamong inner-city youth, particularlyBlack males, in several major cities.

The effects of this unique and com-plex drug vary greatly according tothe dose, manner in which it is taken,and the expectations of the user. Insome users, it evokes feelings ofpower, strength, and invulnerability,followed by depression. PCP maycause agitation and confusion, feel-

c&

4111110111ir


ings of grandiosity, impaired coordi-nation, and incoherent speech. Some-times the effects mimic symptoms ofschizophrenia and result in admissionfor psychiatric treatment. Chronicuse can be quite dangerous in adultsand is associated with increased riskfor memory and speech problems,hallucinations, paranoia, psychoticepisodes, seizures, and death by sui-cide or other violent means. Usersoften combine their PCP consump-tion with cocaine, marijuana, and/oralcohol.

The drug is rather easily made inillegal laboratories, sells at relativelylow cost, and comes in liquid, pow-der, or pill form. It is usually takenorally or mixed with marijuana, pars-ley, mint, or tobacco and smoked incigarettes, but it can also be injected.PCP contains many contaminants.Once consumed, PCP remainsin the brain and in body fats for along time.

Suspected mechanisms for drug dam-age to the fetus: Like most otherdrugs, PCP crosses the placenta inboth animals and humans. In mice, itenters the fetal brain quickly asearly as 15 minutes after the motheris injected but is not detectablethere after 24 hours. In one study, theconcentration in fetal body tissue was10 times higher than in the mother'sblood. No byproducts of PCP werefound, which suggests that the fetalliver does not break it down.

Effects during pregnancy and deliv-ery: Very little research has beenconducted on the effects of PCP onprenatally exposed newborns andinfants. The first descriptive reportswere published in 1980. There havebeen some animal studies and com-parisons between PCP-exposedbabies and infants exposed to differ-ent drugs. One difficulty encounteredby investigators of PCP effects onpregnancy and offspring is the pat-tern of multiple substance use by vir-tually all of the mothers. Variouscombinations of alcohol, cocaine, andmarijuana, along with PCP, arereported.

Effects on breastfeeding: PCP istransmitted to the nursing infant inbreast milk. In animal research, signif-icant activity changes are noted innursing offspring of PCP-usingmothers.

Effects on the newborn: The firstcase reports of newborn behaviorattributed to the mother's heavy andregular consumption of PCP duringpregnancy described extreme jitteri-ness, poor visual coordination, coarseflapping movements in response tovery slight touch or sound stimuli,and abnormal muscular tension. Only1 of the first 3 babies studied hadphysical abnormalities.

A larger study of nine infantswhose mothers primarily used PCPduring pregnancy found these new-

41


born to be more emotionally unsta-ble and less consolable than infantsprenatally exposed to other drugs.Although the PCP-exposed babieshad rapid state changes (alternatingbetween restlessness and calm), theydid not exhibit withdrawal symptoms.

Animal studies suggest that PCPmay cause birth defects. Extremelyhigh doses of PCP cause malforma-tions and abnormal behavior in labo-ratory animals, but these dose levelsare far higher than human consump-tion of the drug. In human studies,which now include approximately 200cases of PCP-exposed offspring, con-genital birth defects have not beenfound. Since most of the mothers inthe largest study abused severaldrugs, this finding needs furtherverification.

Effects on the growing child:Although a leader in both medicalpractice and research on drugs andpregnancy has observed that prenatalPCP damage may not show up untilmonths after birth, findings to datehave not revealed long-term neu-robehavioral deficits. However, onlya few studies with small numbers ofcases have been completed, andmore research is needed.

In followup studies of nine infantswhose mothers primarily abused PCPthroughout pregnancy, mild neuro-behavioral deficits and small-for-agehead circumferences were observedin the PCP-exposed babies during the

first year of development, althoughbody length and weight were in thenormal range. However, by 2 years ofage, no differences were found inmental or psychomotor developmentbetween the PCP-exposed toddlersand normal controls. Since develop-mental scores declined for all thegroups in the study, including differ-ent sets of drug-exposed infants andnormals, the investigator suggeststhat an infant's early caretaking envi-ronment may contribute more to itsnormal development than prenataldrug use by the mother.

Prescription MedicationsAnd Other LicitSubstances

The focus of this booklet is on thedangers to pregnant or nursing moth-ers and their drug-exposed infants ofcommon psychoactive substancesthat are used for nonmedical pur-poses. However, health care profes-sionals counseling women of child-bearing age must help them realizethat many prescribed medications,over-the-counter remedies, vitamins,industrial chemicals, and other envi-ronmental pollutants can also posehazards to their unborn children.Pregnant or lactating mothers shouldroutinely be reminded to report anddiscuss with their doctors any medica-tions and vitamins they take, even ifthese substances have been pre-viously prescribed for them.

327-404 0 - 92 242

`-;


Table 1. FDA pregnancy categories

Category Interpretation

A Controlled studies show no risk. Adequate, well-controlledstudies in pregnant women have failed to demonstrate riskto the fetus.

B No evidence of risk in humans. Either animal findings show risk,but human findings do not or, if no adequate human studieshave been done, animal findings are negative.

C Risk cannot be ruled out. Human studies are lacking, and animalstudies are either positive for fetal risk, or lacking as well.However, potential benefits may justify the potential risk.

D Positive evidence of risk. Investigational or postmarketing datashow risk for the fetus. Nevertheless, potential benefits mayoutweigh the potential risk.

X Contraindicated in pregnancy. Studies in animals or humans orinvestigational or postmarketing reports have shown fetalrisk that clearly outweighs any possible benefit to thepatient.

Some medically useful drugs arealso taken for nonmedical reasons orused in ways the doctor or the pack-age instructions do not recommend.Tranquilizers, sleeping pills, coldremedies, and other commonly useddrugs may be taken more frequentlythan recommended, in larger thanprescribed doses, or over a longertime than indicated. Sometimeswomen share these medicines orexperiment with different mixtures.

As an example of the prescribingdifficulties posed for physicians (andfor scientists and government offi-

cials charged with making publichealth recommendations), there isnew, but as yet inconclusive, evidencefrom several independent studies thatneural tube defects (NTDs) in new-borns may be prevented by makingcertain that women are not vitamindeficient, particularly in the folicacid-containing B vitamins, beforethey become pregnant or in the criti-cal first 6 weeks after conception.Natural folic acid is primarily foundin cooked green vegetables,brewer's yeast, chicken livers, andlentils.


Approximately 1 in every 1,000newborn babies ;.2 the United Stateshas a neural tube defect, the secondmost common birth defect afterDown's syndrome. This very seriousabnormality causes a fatal condition,anencephaly, in which the brainnever develops, or spina bifida, inwhich a portion of the baby's spinalcord is exposed or covered only byskin. If the baby does not die, mentalretardation and paralysis of the lowerportion of the body may result. Veryexpensive surgical and medical treat-ments are usually required.

The women most at risk for deliver-ing babies with NTDs are those withfolic acid-poor diets who are alsolikely to have unplanned pregnancies.Although it might seem sensible torecommend multivitamin supple-ments for all women who are consid-ering pregnancy or who are at risk forunplanned births, several governmentagencies and physician organizationshesitate to do so because excessivedoses of vitamin A can cause birthdefects.

CDC, the National Institutes ofHealth, and the FDA worry that onceyoung women hear that vitamins canprevent fetal damage, they may takelarger than recommended doses,inadvertently harming the babies theycarry. In fact, even at doses that arcnot toxic to adults, vitamin A maycause severe malformations infetuses. Some young women alreadytake large doses of vitamin A for

acne, or may even switch tomegadoses of it when they becomeaware of the prescription drugAccutane's hazards during preg-nancy. Public education about thedangers of thinking "more is better"may be helpful. In the meantime, at-risk women who wish to conceive orare already pregnant need to be cau-tioned about both the potential haz-ards of vitamin deficiency in relationto NTDs and the dangers of overdos-ing on vitamin A.

FDA product-labeling informationpertaining to pregnancy: The FDArequires manufacturers to describeand categorize what is known abouteach marketable drug's potential riskto the fetus, balanced against itspotential benefit to the patient. Thisinformation must be included in aspecial section of the product-label-ing data. The Physician's Desk Refer-ence and several similar annuallyrevised publications contain thisproduct-labeling information formost available drugs. The pregnancycategories are shown in table 1.

Prescription drugs with well-estab-lished adverse effects on prenatallyexposed infants include the following:

Accutane (isotretinoin) anantiacne medication and vita-min A derivative that is associ-ated with such majorabnormalities in prenatallyexposed babies as micro-

44


cephalus (small head withsevere retardation) and defectsof the external ear and cardio-vascular system.

Antibiotics, including tetracy-clines and some sulfanilamides.Tetracyclines used during thelatter half of pregnancy maycause permanent discolorationof a child's teeth.

Antimigraine medicines withergotamine are not recom-mended for pregnant womenand may cause reactions in nurs-ing infants such as vomiting,diarrhea, weak pulse, and unsta-ble blood pressure.

Salicylates including Bufferin,Anacin, Empirin, and otheraspirin-containing medications,when taken by pregnant womenat therapeutic doses close toterm or prior to delivery, maycause bleeding in the mother,fetus, or the newborn infant.Regular use of aspirin in highdoses during the last 6 monthsof pregnancy has been shown toprolong pregnancy and delivery.Aspirin is excreted in humanbreast milk in small amountsand may cause metabolic acido-sis or a rash or affect the blood.

Anticonvulsants such as Dilantin(phenytoin) and other antiseiz-ure medications have been asso-ciated with an increase in heart

malformations, cleft lip and pal-ate, microcephaly, mental defi-ciency, and impaired growthamong prenatally exposedbabies. Nevertheless, preventivetreatment of the mother shouldnot be discontinued during preg-nancy, since there is a strongpossibility that withdrawal maycause seizures, with resultingoxygen reduction and threat tothe fetus. Phenytoin is excretedin low concentrations in humanbreast milk, and women takingthis drug should not nurse.

Hormones contained in birthcontrol pills should not be takenduring pregnancy (especiallythe first 4 months) as fetal expo-sure, even for brief periods, mayincrease the risk of congenitalabnormalities, including heartand limb reduction defects.Exposure to some estrogensduring fetal development hasbeen shown to increase the riskfor vaginal or cervical canceramong adolescent offspring.There have also been rarereports of breast enlargement innursing infants exposed to con-traceptive pills and a decreasein the mother's milk production.

Because many women are pre-scribed or illegally obtain and abusetranquilizers and sedative-hypnotics,their potentially adverse conse-quences for pregnant or nursing

45r-

t


mothers and their babies deserve spe-cial mention. In some parts of thecountry, benzodiazipines are verypopular street drugs, used to boostthe effects of other illicit drugs and/or to relieve withdrawal symptoms.

Tranquilizers: All the benzodiaze-pines (minor tranquilizers) have beenassociated with increased reproduc-tive risks. Use of tranquilizers bypregnant women may complicatedelivery and leave newborns lethar-gic, with respiratory difficulties,apneic spells (episodes of not breath-ing), poor muscle tone, anddecreased sucking ability. These tran-quilizers should be used with cautionduring labor because they candepress infants' respirations.

Diazepam (Valium) consumed dur-ing the first 3 months of pregnancyhas been linked to a fourfold increasein cleft palates, lip anomalies, andother malformations of the heart,arteries, and joints. The risk of thesecongenital defects seems to increasewhen diazepam is combined withsmoking and alcohol use.

A 1989 Swedish case study of eightoffspring of mothers whose excessiveuse of benzodiazepines during preg-nancy was confirmed by blood tests,reported birth defects resemblingthose seen in the fetal alcohol syn-drome. All but one infant were alsosignificantly below average inbirthwcight.

Chlordiazepoxide (Librium) use bymothers during the first 6 weeks oftheir pregnancies has been linked toCNS abnormalities in infants.

Diazepam, when used daily for thelast 2 to 4 months of pregnancy indosages as low as 10 to 15 mg, hasbeen found to result in tremulousnessand other symptoms of withdrawal inthe newborn. Flurazepam (Da lm-ane), given in 30-mg doses for 10days, has been associated with leth-argy and abnormal muscle tone innewborn infants lasting several daysafter birth.

Because diazepam accumulates inbreast-fed infants, it and meproba-mate (Equanil, Miltown), should notbe used by nursing mothers.

Barbiturates: Long-acting barbitu-rates (phenobarbital) taken as anti-seizure medications have also beenassociated with congenital birthdefects resembling FAS. Even short-acting barbiturates (Seconal, Tuinal)have been associated with increasesin birth defects and are not consid-ered safe for use during pregnancy.

Chronic use of barbiturates duringthe last months of pregnancy, atdoses of 60 to 100 mg per day, hasbeen associated with infant with-drawal symptoms appearing 4 to 7days after birth. These typically in-clude high-pitched crying, irritability,tremulousness, and sleep disturbancesthat can persist for months and caninterfere with mother-infant bonding.

r- 046

Counseling WomenAbout Childbearing and

Childrearing Risks

Counseling women aboutthe childbearing andchildrearing risks associ-ated with alcohol and

other drug use is a challenging task.Despite recent research advancesand greater public attention to thesehazards, too many women, as well astheir physicians, are still uninformedor misinformed about the dangers tothemselves and their unborn childrenof using drugs in the period beforeconception, during pregnancy, orwhile nursing. Many still don't recog-nize the very real threat of perinatalHIV infection, AIDS, or syphilistransmission.

Because reproductive choice andsafety arc sensitive issues, health cartprofessionals need to become betterinformed, not only about the facts,but also about how to communicateaccurate information in timely, effec-tive, and nonjudgmental ways.

For more than a decade, innova-tive perinatal programs in severalmajor cities have made pioneering

efforts to meet the special needs ofchemically dependent women andtheir infants. Based on their experi-ence, dedicated staff in these pro-grams offer helpful advice forreaching and working with alcohol-and drug-using pregnant women andtheir babies. Their suggestions aresummarized as follows.

I. Keep messages clear, simple,and realistic.

Education begins with informationand understanding. Despite the com-plexity of the topic, most women donot want to be overwhelmed withdata and extraneous material. Keepto the facts, as briefly as possible. Donot use technical language that willnot be understood. Based on market-ing research, neither sensationalismnor humor are effective approachesin dealing with this serious subject.

Because alcohol and other druguse before conception and duringpregnancy are risk factors over whichmost women have direct control, the

47 t

Counseling Women About Childbearing and Childrearing Risks

Table 2. Sample counseling approaches

Positive Approach Negative Approach

If you stop drinking now,you have a better chance ofhaving a healthy baby.

Your concern for your babywill help you be a good mother.

You will feel better whenyou are sober and so willyour child.

Your drinking has alreadydamaged your baby.

If you really loved yourbaby, you would not drinkso much.

Continued drinking will ruin yourhealth and prevent your childfrom developing normally.

dangers need to be understood. How-ever, if the message is exaggerated ortoo frightening, there is the possibil-ity that women may either ignore thewarning as unrealistic or take it tooseriously, increasing their anxiety andstress. There are many risks in preg-nancy, as in life, and women shouldnot be misled into thinking they,alone, can guarantee a healthy baby.A balanced perspective is needed.

Do, however, stay abreast of popu-lar myths and particularly dangerouspractices by pregnant women in yourspecific community and provide up-to-date and factual information to dis-pel misconceptions and preventhazardous behaviors. Many women,for example, do not realize howpotentially serious and long-lastingthe effects of low birthweight can befor the developing child. They needconvincing, realistic education aboutthe implications. In some inner-city

areas, pregnant women are appar-ently using crack cocaine when laborbegins to reduce the discomforts ofdelivery, not understanding the veryserious dangers this poses to theinfant.

2. Stress the positive.

Pregnant women are more recep-tive to information that emphasizesthe positive, not just negative and dis-couraging "don'ts." Clinicians at theBoston FAS prevention program pro-vide the examples shown in table 2.

3. Don't predict the outcome of aparticular pregnancy.

Remember that statistics are notcases. Even though experts mayagree that certain undesirable effectsare likely to result from maternalalcohol or other drug use duringpregnancy, risk statistics cannot pre-dict a given outcome for a particular

48


person. The odds only specify theoverall probability.

Warnings about risks may evenbackfire if a drug-abusing womangives birth to an apparently healthybaby. The new mother may then con-clude that the experts were wrongand refuse to heed further advice. Itis important, therefore, to word infor-mation about possible negative conse-quences as cautiously as possible.Emphasize the ever-present hopethat the mother may be lucky andescape the odds this time. She can, ofcourse, improve the chances consid-erably by stopping drug useimmediately and following otherhealth recommendations.

4. Deliver personal, individuallytailored messages.

There is no substitute for individ-ual attention. Even brief comments,delivered in person, are more effec-tive than written information oraudiovisual presentations without fol-lowup interpretation or discussion.The concern and interest displayedby the health educator seem to be asimportant as the information itself incommunicating effectively.

Sensitivity to the communicationstyles of different groups can alsoenhance their receptiveness andunderstanding. Special attentionneeds to be directed to mothers whoare isolated from the primary cultureby virtue of poverty, ethnicity, o, lowliteracy. Women from minority

groups often need special encourage-ment to talk about sensitive and per-sonal topics. Asian and Hispanicwomen, for example, are socializednot to ask questions, even when theydo not understand the informationbeing provided. Brochures and post-ers may need translation into nativelanguages or into the local slang andjargon; messages may need changingto reflect relevant and culturallyacceptable themes. Any written infor-mation should be pretested with thenarrowly defined target group tomake certain it is believable, as wellas understandable.

S. Help women assess their risk.

One of the most important contri-butions health care professionals canmake toward reducing the harmfulconsequences of maternal drug abuseis to help women understand andacknowledge their own risk behavior.This requires a combination of sensi-tive observation, direct questioning,and informed testing, with followupsuggestions and support.

Of course, preconception counsel-ing and care are the preferred waysto prevent or reduce the many inter-related medical and psychosocialrisks in addition to alcohol andother drug use that endangerwomen's pregnancies and offspring.Indeed, the 1989 Report of the PublicHealth Service Expert Panel on theContent of Prenatal Care (Caring forOur Future: The Content of Prenatal

49


Caie) recommends that preconcep-tion care be integrated into a varietyof primary care settings to include(1) risk assessment and diagnosis,(2) health promotion and education,and (3) treatment and referral.

These services would be muchmore widely available if they wereroutinely incorporated into schoolhealth examinations, premarital appli-cations, family planning and geneticcounseling, general health care infamily practice or other specialist set-tings, treatment of alcohol and otherdrug abuse problems or sexuallytransmitted diseases, and pediatric orwell-child examinations. As theexpert panel cogently stated:

l3ecau,c health:, %komen arc matelikely to have health\ bahie, a,Nur-imz good health prior to conceptionsimpl% make. a' Nt_1,e and shouldhe -tandard care. Diallnosis andinter:Lntiork to treat medical dine,.and rkcho,ocial rkk- prior to con-ception will eliminate or reduce hat-art; to the mother and bal. . C are kako likch to he more effective priorto cont. eption hecausL ealuationand treatment can he initiated wit h-(.111 harm to the fetu,,.

When taking medical histories andconducting physical examinations,health care practitioners can watchout for illnesses and physical symp-toms associated with drug depen-dency (e.g., hepatitis, vaginalinfections, anemia, nasal inflamma-

tion from cocaine use, track marksfrom drug injection, or stained fin-gers from cigarette smoking). Gyne-cologists and obstetricians can bealert for such problems in patients'previous pregnancies as placentalabnormalities, low birthweightbabies, or an FAS-diagnosed child.

More importantly, physicians andassociated health care professionalsneed to ask childbearing-age womendirect questions about their alcoholand other drug use. A whole litera-ture exists on the most effective waysto imbed screening questions in rou-tine medical history taking appro-priate phrasing and the sequence ofquestions to ask about associatedproblems and use patterns for sub-stances rant ng from tobacco andalcohol through the illicit drugs.

When possible, and with informedconsent, the blood or urine of preg-nant women should be analyzed fordrug metabolites. Objective labora-tory testing seems to encourage moreaccurate responses to drug-historyquestions and is appropriate as ascreening mechanism, if used withsupportive followup counseling.

6. NIntiNate risk reduction andproNide ongoing hope.

Indeed, the whole purpose of ques-tioning women about their drug-usingbehavior is to help them find appro-priate ways to quit or reduce poten-tially harmful use patterns. For thevast majority of women considering

50


pregnancy or those already preg-nant or breastfeeding supportiveeducation will be sufficient. The Seat-tle Pregnancy and Health Program,aimed at reducing smoking and drink-ing among pregnant women, foundthat women who were only occasion-al drinkers responded positively tomedia campaigns, even when this wasthe only information source. Moder-ate drinkers were more likely to stopdrinking if messages were conveyedpersonally. However, sizable percent-ages of both groups quit or reducedpotentially dangerous drug use inresponse to widespread public educa-tion emphasizing positive behavior.

Motivation to stop dangerousbehaviors can be increased consider-ably if the woman is engaged in set-ting her own realistic goals forpositive change, if she is supportedby relevant suggestions and attaina-ble interim steps, and if achievementis consistently praised while behavioris monitored over time. A one -shoteffort is not sufficient.

Even if drugs have been used dur-ing the pregnancy, emphasize thebenefits of quitting as soon as possi-ble, following medical advice andsupervised withdrawal if drug or alco-hol use is heavy and chronic.Research indicates that the develop-ing fetus may have a chance to catchup in growth and to recuperate fromsome types of drug-related damage ifthe mother's use is reduced or haltedafter pregnancy begins. For example,

women who quit smoking cigarettesby the fourth month of pregnancyhave no higher risk of delivering lowbirthweight babies than nonsmokers.Similarly, when heavy drinking ceasesearly enough during pregnancy andmaternal nutrition improves, out-comes for the babies also improvesubstantially.

Other studies have shown that ba-bies whose mothers took heroin orPCP while pregnant were eventuallyable to catch up with normal chil-dren. Babies' brains, with properstimulation and caretaking, are sur-prisingly pliable and may be able toovercome some subtle forms of neuro-logical damage. It should be noted,however, that long-term followupstudies are still needed in this area,and the findings to date are not allconsistent.

7. Recommend drug abusetreatment when patient-physician goals for abstentionare not easily achieved.

Because "safe" limits for alcoholand other drug use during pregnancycannot be established, most healthcare professionals advise total absti-nence from all nonessential medica-tions, beginning before conceptionand continuing through breastfeed-ing. This is a simple message thatmost women will try to follow,although it may not be appropriateadvice for all.


This is particularly true for chemi-cally dependent women, who needsensitive intervention and referral forfurther counseling and treatment tohelp them attain and maintain absti-nence. As one prominent chemicaldependency specialist states, "Awoman who continues to use drugsafter she becomes aware of the dan-ger to her unborn child probably ismore addicted than abusive and can'tquit." Repeated warnings, withoutoffering a realistic treatment alterna-tive, are likely to frustrate both thehealth care worker and the patient.

Making a good referral can be verydifficult. Many drug treatment pro-grams will not accept pregnantwomen; there are waiting lists for anyform of publicly funded substanceabuse treatment in many major cities,particularly residential facilities; andmatching a woman with the mostappropriate and available type ofcare further complicates the process.Even though chronic drug abusersseldom limit themselves to one sub-stance, the interventions for smoking,alcoholism, and various other drugaddictions arc often handled sepa-rately. Services are also provided in avariety of settings, including hospi-tals, halfway houses, therapeutic com-munities, daycare centers, andambulatory clinics.

Ideally, a chemically dependentpregnant woman should be providedwith comprehensive, one-stop serv-ices, including prenatal supervision,

obstetrical care, psychosocial counsel-ing, and followup postnatal supportat a specialty perinatal center. Hermultiple health, social, legal, psycho-logical, recreational, childcare, andvocational-economic needs should beaddressed simultaneously throughcase management and appropriatereferral, using a team ofprofessionals.

Because the many problems ofdrug- abusing women, pregnantaddicts, and their children are prior-ity concerns, the Federal Govern-ment is requesting more resourcesfor outreach, treatment, and researchactivities in this area. The Offices forSubstance Abuse Prevention andMaternal and Child Health arejointly funding model demonstrationprograms on prevention, education,and early intervention with substance-abusing pregnant and postpartumwomen and their infants. NIDA isalso awarding grants for research anddevelopment of outreachapproaches, as well as efficacioustreatment and intervention servicesfor this population. States are alsobeing encouraged to make preven-tion and treatment services for alco-hol-and other drug-abusing women apriority concern. At least one State(California) now requires that prior-ity be given to pregnant women seek-ing treatment for alcohol or etherdrug abuse.

Until appropriate drug abuse andalcoholism treatment services for

52

Oti


pregnant women and their offspringare well publicized and available inevery community, health care work-ers will need to become familiar withlocal resources and the exis' mg treat-ment network. The most commontherapeutic approaches, which maybe applied separately or in combina-tion, are the following:

Pharmacotherapy using otherdrugs as a medically supervisedalternative for maintenance ordetoxification (e.g., metha-done), for blocking or inhibitingparticular effects, or for symp-tomatic relief of undesirableside effects of withdrawal

Behavioral management usingprofessional verbal therapy orpeer counseling and the numer-ous self-help approaches, indi-vidually or in groups, con-tingency contracts, learning andskill development, or positiveand aversive conditioning

Environmental controls sepa-rating the abuser and the drugsin residential services orthrough changes in peer groupsand intimates

Most of the pharmacotherapeutictreatment approaches are contraindi-cated for pregnant women because ofthe drugs' known or suspected ter-atogenic effects (e.g., Antabuse ther-apy for alcoholics). However, specialmention should be made of mctha-

done treatment for opioid depen-dence. This is often the preferredtreatment for pregnant women whoseheroin-addicted lifestyles pose sub-stantial risks for their unborn babies.These include not only continuinguse of a variety of drugs, but alsoHIV infection, serious medicalillnesses, poor nutrition, and lack ofprenatal care.

Although prenatal exposure tomethadone is likely to produce someundesirable consequences for thefetus and the newborn, many special-ists who have evaluated these hazardsfor more than 20 years believe thatparticipation in a well-supervisedtreatment program where a carefullycontrolled and individually tailoredmaintenance methadone dose can beadministered throughout pregnancyis a less risky alternative than continu-ing heroin abuse. Methadone treat-ment is also an effective AIDSprevention strategy. Federal regula-tions governing aspects of methadonetreatment programs now require spe-cial consideration for pregnantpatients.

8. Be sensitive to the legalimplications.

The subject of drug use duringpregnancy, while attracting more sci-entific interest and research, is simul-taneously evoking heated public andpolitical controversy. One center ofcurrent debate is the potentialcriminalization of prenatal drug use.

53


In some States, a mother's failure tostop using specified illegal drugs dur-ing pregnancy may be consideredchild abuse or neglect. In cases wherethe newborn tests positive for thesesubstances at delivery, hospitals maybe required to report this informa-tion. The child could then be takeninto protective custody and placed inthe care of a social service agency. Inmore extreme cases, the mother mayeven be charged with breaking thelaw.

Legal requirements for reportingalcohol and other drug use by preg-nant women vary by State and areevolving rapidly. There is no clearconsensus yet about how to balanceand protect the rights of an unborninfant with the rights of the infant'smother. However, the dominantemerging view from a variety of pro-fessional specialists in health care,child welfare, and the law is toapproach adverse consequences ofprenatal and postnatal drug use associal-medical problems, not readilyamenable to punitive legal sanctions.

Meanwhile, health care workersneed to keep abreast of legal develop-ments and to be sensitive to theirimplications when drug abuse by apregnant woman is suspected and atreatment referral is suggested. Somewomen will avoid drug treatment orprenatal care if the responsibilities ofhealth care workers are not under-stood or if their motivations areviewed with suspicion.

9. Provide special help withparenting.

Mothers who deliver babies withphysical defects, withdrawal symp-toms, or other problems of prematu-rity or low birthweight need specialhelp. Their anxiety and guilt arelikely to interrupt important infant -mother attachment processes. Ababy's prolonged stay in the hospital,as well as the infant's irritability andadjustment difficulties, can frustratethe mother and increase her stressand anxiety. She will desperatelyneed understanding guidance andvery specific training in how to carefor this needy infant.

Special parenting skills are alsoneeded for babies whose neurologi-cal impairment is not discovered formonths or years after birth. Mothersand fathers need to recognize thedevelopmental milestones of normalgrowth and what a difference theirloving attention can make in overcom-ing a child's learning deficiencies,behavioral problems, or attentionaldeficits. Some educators believe thatdevelopmental outcomes after birthare more related to environmentalconditions and r9sponsive caretakingthan to prenatal difficulties. Specifichelp can be provided in infant stimu-lation or play therapy, as well as par-ent training, for these mothers andfathers, some of whom may havelacked adequate nurturingthemselves.

54

Summary

Although prenatal drug exposureis associated with a variety of effectson the fetus and the developing child,there are a number of similarities inthe consequences resulting frommaternal use of the different drugsdiscussed in this booklet. Here aresome generalizations that can bemade about the childbearing risksinvolved and other findings fromresearch in this area:

When a mother uses drugs, herunborn or nursing infant is alsoaffected. During gestation,almost all drugs cross the pla-centa and enter the blood-stream of a developing baby. Abrcastfecding mother's milkalso contains the drugs shetakes.

Drug use during the early weeksof pregnancy, from the fourth tothe eighth weeks following con-ception, is more likely to causespontaneous abortions or notice-able physical abnormalities inthe newborn than use later inthe pregnancy. Many women donot even realize they are preg-nant during this very importantperiod when the major skeletal

and organ systems arc formingand are most vulnerable to toxiceffects from drug exposure.

After the eighth week of preg-nancy, maternal drug use ismore frequently associated withgrowth retardation, prematu-rity, and neurological damage tothe infant. Drug use near thetime of delivery may precipitatelabor and can be hazardous.Both prematurity and lowbirthweight are related to veryserious problems in younginfants, including increasedrates of respiratory illness, sud-den infant death syndrome,infections, and developmentaldelays.

Sometimes a mother's physicalhealth requires medications thatpose some risk for her unbornbaby. Then, physician-patientagreement is needed on themost sensible course of treat-ment, balancing the mother'sneed against potential harm toher fetus. Medically supervisedmaintenance on methadone forheroin-using mothers is anexample of this type of dccision-

55

Summary

making, as is the choice of anappropriate anticonvulsant for apregnant woman with epilepsy.

Women who smoke cigarettes,drink alcoholic beverages, oruse illicit drugs during preg-nancy increase their risks forobstetrical complications andfor premature labor and deliv-ery. They are also more likelythan abstaining mothers to suf-fer fetal losses through sponta-neous abortions, miscarriages,and stillbirths.

Prenatally drug-exposed infantsare also at risk for a variety ofadverse consequences, includ-ing death before their first birth-days. In utero drug exposure isadditionally associated with anincreased rate among newbornsof (1) low birthweight, withsmall-for-gestational-age lengthand head size, (2) central ner-vous system damage that maydelay or impair neurobehavioraldevelopment, (3) mild to severewithdrawal effects, and (4) cer-tain congenital physical malfor-mations (e.g., cleft palate, heartmurmurs, eye dcfects, andabnormalities of facial featuresand other organ systems).

Risks arc related to the amountof the drug taken by the motherand the stage of pregnancywhen embryonic or fetal expo-sure occurs. The heavier and

more persistent the mother'sdrug use, the more likely therewill be adverse consequences.The sooner a woman stopsusing drugs during pregnancy,the greater her chances for hav-ing a healthy baby. Even cuttingdown on tobacco, alcohol, andother drug use while pregnantcan reduce the risks to theunborn.

The surest way to avoid harm-ing the baby is to stop taking allunnecessary drugs, preferablybefore pregnancy begins.Chronic drug abuse can alsointerfere with a woman's fertil-ity, causing menstrual cessationor irregularities, ovulation prob-lems, and changes in sexualfunctioning.

Not all babies show negativeeffects from prenatal exposureto drugs. A variety of geneticfactors in the unborn baby andmaternal characteristics, as wellas differences in the chemicalstructure of drugs and their usepatterns, interact to influencethe vulnerability of the unbornbaby. No one can say for certainwhich baby will be all right andwhich will have abnormalities.Drug-related effects may beworse if the mother has a poordiet, little exercise, medicalillnesses, inadequate prenatalcare, or other complications ofpregnancy.

56

Summary

The majority of pregnantwomen can and do stop usingalcohol and other drugs or cutback considerably once theyrealize the dangers. Chemicallydependent women, however,are not so likely to change theiraddictive drug use patterns with-out help. For them, giving updrugs, whether cigarettes, alco-hol, or other psychoactivedrugs, is more easily said thandone. These expectant mothersoften need professional treat-ment and certainly need a com-prehensive and reliable supportsystem to help them abstain andremain drug free.

Because of legal and socialinterests in protecting babies, apregnant woman who continuesto take drugs against medicaladvice risks losing custody ofher baby after it is born. Insome States, she also risks crimi-nal prosecution.

Although maternal consump-tion of specific drugs can pro-duce particular effects in thedeveloping fetus and growingc._ild, the negative conse-quences of alcohol, cigarette,and illicit drug use in pregnancyoften seem more alike than dif-ferent. This is partly becausemany women use more than onedrug while pregnant, making itdifficult to separate confound-ing and interactive effects of

multiple drug use in theresearch findings. Women whodrink are also very likely tosmoke. Many others use, but donot reliably report, illicit drugs,prescription medications, andover-the-counter remedieswhile pregnant.

Newborns with drug-relatedimpairments are often difficultto handle. To avoid maternal-infant bonding problems andfeelings of failure or rejection inthe mother, expert guidanceand dependable support serv-ices are needed after thebabies are born, sometimes formonths.

In many cases, drug-associateddeficits only become apparentas a child matures. Mental retar-dation, lowered intelligence,hyperactivity, shortened atten-tion spans, learning and organi-zational disorders, impairedphysical coordination, continu-ing growth delays in height,weight, and head size, andsocial-interpersonal adjustmentproblems are found with greaterregularity among prenatallydrug-exposed youngsters thanin similar children whose moth-ers did not use drugs duringpregnancy.

In the long run, a baby's caretak-ers and learning environmentare as important as the mother's

57

Summary

prenatal drug use for healthygrowth and development. Astimulating and supportive fam-ily life is vital for overcoming orameliorating damage to thechild from drug exposure in theuterus. Many mothers and

111111111f

fathers from impoverishedbackgrounds need help withparenting skills, as well as withother psychosocial and eco-nomic problems. Ultimately, thebest hope for any child is ahealthy and nurturing family.

58

For More Information

Selected Health Information Clearinghouses

Clearinghouse on Child Abuse and Neglect InformationP.O. Box 1182Washington, DC 20013703/821-2086

National Center for Clinical Infant Programs(publishes the Bulletin Zero to Three)2000 14th Street North, Suite 380Arlington, VA 20001703/528-4300

National Center for Education in Maternal and Child Health38th and R Streets, NWWashington, DC 20005202/625-84.00

National Clearinghouse for Alcohol and Drug Information (NCADI)P.O. Box 2345Rockville, MD 20852301/468-2600; 1-800/729-6686

National Maternal and Child Health Clearinghouse38th and R Streets, NWWashington, DC 20057202/625-8410

Office on Smoking and HealthTechnical Information Center5600 Fishers Lane, Park Bldg., Room 116Rockville, MD 20857301/443-1690

11111111111111111111111P

327-404 0 - 92 - 3 59 r :";


Compendiums of Resources

Healthy Mothers, Healthy Babies: A Compendium of Program Ideas forServing Low-Income Women, January 1986.

Available from the National Maternaland Child Health Clearinghouse202/625-8410

Describes strategies used by 1,500 programs nationwide a new supplement isbeing prepared. Focuses on reproductive issues from prepregnancy through post-natal services and on special populations.

Reaching Out: A Directory of National Organizations Related to Maternal andChild Health, March 1989.

Avaimble from The National Maternaland Child Health Clearinghouse202/625-8410

Lists organizations by age group and health topic area. Also lists self-help clear-inghouses by State.

Starting Early: A Guide to Federal Resources in Maternal and Child Health,November 1988.

Available from The National Maternaland Child Health Clearinghouse202/625-8410

Lists publications and audiovisual materials by health topic.

Drug Abuse Information and Referrals in the Special Supplemental FoodProgram for Women, Infants, and Children: A Resource Manual for ProgramDevelopment, March 1990

Available from the WIC Supplemental Food Program,Food and Nutrition Service, U.S. Dept. of Agriculture202/756-3730

Annotated bibliography of written and audiovisual materials to educate staff andlow literacy clients about the hazards of drug use during pregnancy and breast-feeding.

60


Publications and Pamphlets

American Cancer Society (or local chapters)1599 Clifton Road, NEAtlanta, GA 30329404/320-3333

Materials to help stop smoking.

American Council for Drug Education204 Monroe Street, Suite 110Rockville, MD 20852301/294-0600

Materials on drugs and pregnancy and specific drugs.

American College of Obstetricians and Gynecologists (ACOG)409 12th Street, SWWashington, DC 20024202/638-5577

Materials on birth control, nutrition, and prenatal care.

American Lung Association (or local chapters)1740 BroadwayNew York, NY 10019212/315-8700


American Red Cross (or local chapters)Chapter Headquarters2025 E Street, NWWashington, DC 20002202/737-8300

Courses and training of trainers for prenatal care and nutrition.

Healthy Mothers, Healthy Babies Coalition (or State chapters)409 12th Street, SW, Room 309Washington, DC 20024202/638-5577 or 863-2458

Information and education to improve maternal/infant health.

61


La Leche League International, Inc.9616 Minn:Apolis Ave, P.O. Box 1209Franklin Park, IL 60131708/455-7730

Materials on breastfeeding.

March Of Dimes Birth Defects Foundation (or local chapters)1275 Mamaroneck AvenueWhite Plains, NY 10605914/428-7100

Materials on prenatal care, drugs and pregnancy. Copies of some pamphlets andother materials in Spanish.

National Association for Children of Alcoholics31582 Coast Highway, Suite BSouth Laguna, CA 92677714/499 -3889

Materials and support groups for children of alcoholics.

National Association for Perinatal Addiction Research and Education(NAPARE)

11 East Hubbard Street, Suite 200Chicago, IL 60611312/329-2512

Materials, curricula, and conferences on drugs and pregnancy.

National Cancer InstituteOffice of Cancer CommunicationsBuilding 31, Room 10A24Bethesda, MD 208921-800-4-CANCER


National Council on Alcoholism and Drug Dependence, Inc.12 West 21st Street, Eighth FloorNew York, NY 100101-800-NCA-Call; 212/206-6770

Materials on alcoholism, FAS, and FAE.

kJ 62


National Head Start Association1220 King Street, Suite 200Alexandria, VA 22314703/739-0875

Materials and support for preschool education and parenting.

National Sudden Infant Death Syndrome Clearinghouse8201 Greensboro Drive, Suite 600McLean, VA 22102703/821-8955

Materials to explain this serious risk associated with drug use during pregnancy.

Planned Parenthood Federation of America, Inc.810 Seventh AvenueNew York, NY 10019212/541-7800

Materials on family planning.

Teratology Society (or State chapter)9650 Rockville PikeBethesda, MD 20814301/571-1841

Information on specific teratogenic agents.

Help With Treatment Referrals

A variety of self-help groups are available in local communities. These includeAlcoholics Anonymous, Al-Anon, Adult Children of Alcoholics, Cocaine Anony-mous, Narcotics Anonymous, Parents Anonymous, and Women for Sobriety.Listings of meetings can be obtained from headquarters offices with telephonenumbers in local directories.

Local affiliates of the National Council on Alcoholism and Other Drug Abusesometimes provide cferral services, not only to public facilities but also to privateprograms, therapists, and physicians.

Contact alcohol and other drug abuse treatment programs in local hospitals andhealth centers, listed in the telephone directory under alcohol, alcoholism, drugtreatment, and similar headings. Some directories list human services agencies inthe front section of the white pages.

63

t)


The National Association of State Alcohol and Drug Abuse Directors(NASADAD) keeps a current list of agencies and directors in each State thatoversee alcohol and other drug abuse prevention and treatment activities. TheNASADAD telephone number is 202/783-6868.

The National Clearinghouse for Alcohol and Drug Information (listed above) canprovide some information on where to call in various States and regions of thecountry. The Clearinghouse telephone number is 301/468-2600.

The National Institute on Drug Abuse Treatment Referral Hotline directs drugusers and their families to drug treatment facilities in local communities. Thetelephone number is 1-800-662-4357.

Recommended For Further Reading

ALCOHOL AND PREGNANCY

For Staff

Alcohol and Birth Defects: The Fetal Alcohol Syndrome and RelatedDisorders, 1987.

DHHS Pub. No. ADM 87-1531Peter L. PetrakisAvailable through NCADI: 301/468-2600.

A 56-page publication summarizing current clinical and animal research relatedto fetal alcohol effects and FAS. Bibliography included.

Preventing Alcohol-Related Birth Defects, Fall 1985.Alcohol Health and Research World, Special Issue. 10:(1)Available through NCADI: 301/468-2600; 1-800-729-6686.

Preventing Fetal Alcohol Effects, 1981.R. J. Sokol, S.I. Miller, and S.S. MartierSuperintendent of Documents, U.S. Government Printing OfficeWashington, DC 20402

A 20-page guide for health care professionals to use in screening and identifyingpatients who use alcohol during pregnancy. Single copies free. May be duplicated.

64


Special Population Module on FAS/FAE, 1988.A.P. Streissguth, Ph.D.University of Washington Medical SchoolDepartment of Psychiatry and Behavioral SciencesSeattle, WA 98195

A 15-page manual for health educators trying to prevent FAS/FAE. Bibliographyand annotated list of model programs and materials on FAS. Single copies free.

For Clients

My Baby ... Strong and Healthy, 1986/Reprinted 1988.DHHS Pub. No. (ADM)86-1436Available through NCADI: 301/468-2600; 1-800-729-6686.

A 16 -page, illustrated booklet depicts alcohol as a drug, discusses effects ofdrinking on the fetus, provides alternatives to drinking during pregnancy, anddescribes the dangerous interactive risks when drinking is mixed with smoking andother drug use. (Spanish version Hi Bebe...Fuerto y Sano).

Alcohol and PregnancyHealth and Nutrition Service of Racine, Inc.2316 Rapids DriveRacine, WI 53404414/637-7750

A fact sheet suitable for low-literacy clients that discusses how alcohol can damageunborn babies, FAS, and some suggestions for abstaining. Single copies are freeand can be duplicated.

Alcohol and Your Unborn Baby, 1984.American College of Obstetricians and Gynecologists409 12th Street, SWWashington, DC 20024202/638-5577

Eight pages of discussion about alcohol use during pregnancy, with guidelines forthe prevention of FAS. Single copies are free.

Will Drinking Hurt My Baby? 1986.March of Dimes Birth Defects Foundation (or local chapters)1275 Mamaroneck AvenueWhite Plains, NY 10605914/428-7100

An easy-to-read 2-page pamphlet that summarizes the dangers of drinking duringpregnancy and defines FAS. Single copies free and dupli, tion permitted.

111111111.11111111111111111

65


TOBACCO AND PREGNANCY

For Staff

Smoking and Reproductive Health, 1987.M.J. Rosenberg, editorLittleton, MA: PSG Publishing Co.

Smoking and Pregnancy: Kit for Health Care ProvidersThe American Lung Association1740 Broadway, New York, NY 10019212/315-8700

Contains a handbook for counseling the pregnant woman who smokes, a flip chart,two posters for display, and two leaflets to give to patients. Also available fromlocal affiliates.

Helping Smokers QuitThe National Cancer Institute, Office of CommunicationsBuilding 31, Rm 10A-24Bethesda, MD 208921-800-4-CANCER

Contains a guide for physicians, a test for patients, tips for quitting, facts aboutwhat happens after quitting, and posters.

Special Delivery: Smoke Free Facilitator's Guide, 1988.The American Cancer Society (or local chapters)1599 Clifton Road, NEAtlanta, GA 30329404/320-3333

A program to help women stop smoking during pregnancy, with accompanyingvideotape. Single copies free.

Why Start Life Under A Cloud? 1986.The American Cancer Society (or local chapters)1599 Clifton Road, NEAtlanta, GA 30329404/320-3333

A short pamphlet discussing the effects of smoking on unborn babies. The readinglevel is too sophisticated for low literacy clients, but could be explained by staff.

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For Clients

Babies Don't Thrive in Smoke-Filled Rooms, 1986.March of Dimes Birth Defects Foundation (or local chapters)1275 Mamaroneck AvenueWhite Plains, NY 10605914/428-7100

A brief 4-page pamphlet that highlights risks of smoking during pregnancy.

Facts About Smoking and Pregnancy, 1984.Tineke BoddeNational Institute of Child Health and Human Development, 9000 Rock-ville Pike, Building 31, Room 2A32Bethesda, MD 20895301/496-5133.

An illustrated brochure summarizing the research findings on the impact ofmaternal smoking on the developing fetus.

Freedom from Smoking for You and Your Baby, 1986.American Lung Association1740 Broadway, New York, NY 10019212/315-8700

A 10-day self-help guide for mothers to stop smoking. Includes a progress record.Copies are $1.40 each.

I Quit Smoking Because I Love My Baby, 1982.American Lung Association (see above)

An 8-page booklet describing the reasons why mothers should not smoke whilepregnant, emphasizing the benefits of quitting at any time.

Pregnant? That's Two Good Reasons to Quit Smoking, 1983.National Institute of HealthNHLBI Smoking Educational Program Information Center4733 Bethesda Avenue, Suite 530Bethesda, MD 20814301/951-3260

Brief 8-page booklet describes risks and encourages mothers to quit smoking.There is an accompanying poster. Single copies free.

67


DRUGS AND PREGNANCY

For Staff

The Fact Is .... Alcohol and Other Drugs Can Harm an Unborn BabyAvailable from NCADIP.O. Box 2345Rockville, MD 20852301/468-2600; 1-800-729-6686

This 13-page fact sheet summarizes the risks associated with prenatal use ofalcohol and other drugs and lists books, journals, brochures, audiovisuals, andother resources on this topic.

Drugs, Alcohol, and Pregnancy, 1988.Christina DyeDo It Now PublicationsP.O. Box 21126Phoenix, AZ 85036602/491-0393

A 24-page booklet covering everyday social toxicants, prescription medications,illicit substances, and "non-drug" drugs in the context of a healthy pregnancy.Includes a section on breastfeeding. Price not available.

Drugs and Pregnancy: It's Not Worth the Risk, 1986.American Council for Drug Education204 Monroe Street, Suite 110Rockville, MD 20850301/294-0600

Developed to help physicians identify and refer patients who use drugs duringpregnancy, this 36-page booklet summarizes recent resea.-ch on maternal drug useand other factors affecting risk levels during pregnancy. Copyrighted. Copies are$3.00 each.

For Clients

Drugs, Alcohol, lobacco Abuse During Pregnancy, 1987.March of Dimes Birth Defects Foundation (or local chapters)1275 Mamaroneck AvenueWhite Plains, NY 10605914/428-7100

A two-page pamphlet with basic facts about the effects on the fetus and newbornfrom exposure to tobacco, alcohol, prescription drugs, antacids, aspirin, laxatives,

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vitamins, caffeine, and uppers, downers, and street drugs. Single copies are free,and duplication is permitted.

I Want To Have a Healthy, Happy Baby, 1988.Trish MagyariGeorgetown University Child Development Center3800 Reservoir Road, NWWashington, DC 20008202/687-8635

A 6-page pamphlet describing the dangers of alcohol, cigarettes, and other druguse during pregnancy. Also discusses risks for AIDS. Developed for a primarilyBlack, inner-city audience in the District of Columbia. Single copies free andduplication permitted.

69'

Bibliography

Abel, E.L. Prenatal exposure to cannabis: A critical review of effects on growth,development, and behavior. Behavioral and Neural Biology 29(2):137-56,1980.

Abel, E.L. Marijuana and sex: A critical survey. Drug and Alcohol Dependence8:1-22, 1981.

Abel, E.L., and Sokol, R. Fetal alcohol syndrome is now the leading cause of mentalretardation. Lancet 2:1222, 1986.

Aker, D., et al. Abruptio placentae associated with cocaine use. American Journalof Obstetrics and Gynecolog 146:220-221, 1983.

Alcohol, Drug Abuse, and Mental Health Administration. Illicit drug use in U.S.shows steep drop except cocaine addiction. ADAMHA News 15(6):1,16,1989.

Alcohol, Drug Abuse and Mental Health Administration. The high risk of cocaine,other drugs. ADAMHA News. 15(9):3,12, 1989.

Alroomii, L.G., et al. Maternal narcotic abuse and the newborn. Archives of Diseasein Childhood 63:81-83, 1988.

Baird, D.D., and Wilcox, A.J. Cigarette smoking associated with delayed concep-tion. Journal of the American Medical Association 253(20):2979-83, 1985.

Bauchner, H.; Zuckerman, B.; McClain, M.; Frank, D.; et al. Risk of sudden infantdeath syndrome among infants with in utero exposure to cocaine. Journal ofPediatrics 113:831-834, 1988.

Besharov, D.J. The children of crack: Getting serious about protection. PublicWelfare draft version submitted for pul,lication in fall 1989.

Bingol, N.; Fuchs, M.; et al. Teratogenicity of cocaine in humans. Journal ofPediatrics 110:93-96, 1987.

Bouknight, L.G., and Bouknight, R.R. Cocaine: A particularly addictive drug.Postgraduate Medicine 83(4):115-131, 1988.

Braielton, T.B. Neonatal Behavioral Assessment Scale. Philadelphia: Lippincott,1973.

71

Bibliography

Chaney, N.E. et al. Cocaine convulsions in a breast-feeding baby. Journal of

Pediatrics 112:134-35, 1988.Chasnoff, I.J. Cocaine intoxication in a breast -fed infant. Pediatrics 80:836-38, 1987.

Chasnoff, I.J., ed. Drugs, Alcohol, Pregnancy and Parenting. Boston: Kluwer Aca-

demic Publishers, 1988.Chasnoff, I.J. Opening statement at National Association for Perinatal Addiction

Research and Education (NAPARE) conference in New York City, Aug. 28,

1988.Chasnoff, I.J. "First Nationwide Hospital Survey on the Inci&nce of Drug Use in

Pregnancy." Presentation at NAPARE conference in New York, Aug. 28, 1988.

Chasnoff, I.J. Pinellas county study: Illegal drug use across socio-economic lines.

Office for Substance Abuse Prevention Special Report #1 to the T7zird National

Learning Community Conference. (Re: Pregnant and Postpartum Womenand Their Infants). Feb. 1990.

Chasnoff, I.J., et al. Phencyclidine: Effects on the fetus and neonate. Developmen-

tal Pharmacology and Therapeutics 6:404-08, 1983.

Chasnoff, ct al. Maternal cocaine use and genitourinary tract malformations.

Teratology 37:201-04, 1988.

Chasnoff, I.J., et al. Temporal patterns of cocaine use in pregnancy. Journal of the

American Medical Association 261:1741-44, 1989.Chasnoff, I.J.; Burns, K.A.; Burns, W.J.; and Schnoll, S.H. Prenatal drug exposure:

Effects on neonatal and infant growth and development. Neurobehavioral

.'oxicology and Teratology 8:357-362, 1986.Chasnoff, U.; Burns, K.A.; and Burns, W.J. Cocaine use in pregnancy: Perinatal

morbidity and mortality. Neurotoxicology and Teratology 9:291-293, 1987.

Chasnoff, 1.J.; Burns, W.J.; Schnoll, S.H.; and Burns, K.A. Cocaine use in preg-

nancy. New England Journal of Medicine 313:666-669, 1985.

Chasnoff, I.J.; Schnoll, S.H.; Burns, W.J.; and Burns, K. Maternal nonnarcoticsubstance abuse during pregnancy: Effects on infant development. Neuro-behavioral Toxicology and Teratology 6:277-280, 1984.

Cherukuri, R., ct al. A cohort study of alkaloidal cocaine (crack) in pregnancy.

Obstetrics and Gynecology 72(2):147-51, 1988.

Choutrcau, M., et al. The effect of cocaine abuse on birth weight and gestational

age. Obstetrics and Gynecology 72:351-54, 1988.

Clarren, S.K.; Bowden, D.M.; and Asticy, S. The brain in the fetal alcohol syn-drome. Alcohol Health and Research World 10(1):20, 1985.

Li

72

Bibliography

Cohen, S. Recent developments in the abuse of cocaine. Bulletin on Narcotics36(2):3-14, 1984.

Coles, C.D., et. al. Neonatal ethanol withdrawal: Characteristics of clinicallynormal, non-dysmorphic neonates. Joum, t of Pediatrics 105(3):445-451,1984.

Connolly, W. "Legal Issues in Perinatal Addiction: An Overview." Presentation atNAPARE conference in New York City, Aug. 29, 1988.

Cooper, J.E.; Cummings, A.J.; and Jones, H. The placental transfer of PCP in thepig: Plasma levels in the sow and its piglets. Journal of Physiology 267:17P-18P, 1977.

Counsilman, J.J., and Mackay, E.V. Cigarette smoking by pregnant women withparticular reference to their past and subsequent breast-feeding behavior.Australian and New Zealand Journal of Obstetrics and Gynaecology 25(2):101-107, May, 1985.

Cox, S.M., (;! al. Bacterial endocarditis, a serious pregnancy complication. Journalof Reproductive Medicine 33(7):671-74, 1988.

Creglcr, L.L. Adverse health consequences of cocaine abuse. Journal of theNational Medical Association 81(1):27-38, 1989.

Deltario, S.L. Perinatal or adult exposure to cannabinoids alters male reproductivefunctions in mice. Pharmacology, Biochemistry and Behavior 12:143453,1980.

DesJarlais, D.C., and Friedman, S.R. Transmission of human immunodeficiencyvirus among intravenous drug users. In: Devita, et al., eds. AIDS: Etiology,Diagnosis, Treatment, and Prevention, Second Edition. Philadelphia: Lip-pincott, 1988.

Doberczak, T.M., et al. Neonatal neurologic and clectroencephalographic effectsof intrauterine cocaine exposure. Journal of Pediatrics 113:354-58, 1988.

Doering, P.L.; Davidson, C.L.; LaFauce, L.; and Williams, C.A. Effects of cocaineon the human fetus: A review of clinical studies. DICP, The Annals ofPharmacotlzerapy 23(9):639-645, 1989.

Edelin, K.C., et al. Methadone maintenance in pregnancy: Consequences to careand outcome. Obstetrics and Gynecology 71(3):399 -404, 1988.

Federal Register. Food and Drug Administration: Methadone; Rule. 21CFR, Part291, March 2, 1989.

Fehr, K.O'B., and Kalant, H., eds. Addiction Research Foundation and WorldHealth Organization Meeting on Adverse Health and Behavioral Consequencesof Cannabis Use. Toronto: Addiction Research Foundation, 1983.

73

Bibliography

Fico, T.A., and Vanderwende, C. Phencyclidine during pregnancy: Fetal brainlevels and neurobehavioral effects. Neurotoxicology and Teratology 10:349-354, 1988.

Finnegan, L.P. Neonatal abstinence syndrome: Assessment and pharmacotherapy.In: Rubatelli, F.F., and Granati, B., eds. Neonatal Therapy: An Update. NewYork: Elsevier, 1986.

Frank, D.A.; Zuckerman, B.S.; Amaro, H.; et al. Cocaine use during pregnancy:Prevalence and corri-lates. Pediatrics 82:888-895, 1988.

Fried, P.A.; Barnes, M.V.; and Drake, E.R. Soft drug use after pregnancy com-pared to use before and during pregnancy. American Journal of Obstetricsand Gynecology 151(6):787-92, 1985.

Golden, N.L., et al. Angel dust: Possible effects on the fetus. Pediatrics 65:18-20, 1980.

Goodman, L.S., and Gilman, A. The Pharmacological Basis of Therapeutics. FourthEdition. New York: Macmillan, 1970.

Greg, J.E.M., et al. Inhaling heroin during pregnancy: Effects on the baby. BritishMedical Journal 296:754, 1988.

Griffith, D.R. "Mother/Infant Interaction." Presentation at NAPARE conferencein New York City, Aug. 29, 1988.

Griffith, D.R. "Neurobehavioral Assessment of the Neonate." Presentation atNAPARE conference in New York City, Aug. 30, 1988.

Haddow, J.E. Second trimester scrum catinine levels in nonsmokers in relation tobirth weight. Journal of the American Medical Association 261(1):33, 1989.

Hill, L.M., arid Kleinberg, F. Effects of drugs and chemicals on the fetus andnewborn. Mayo Clinic Proceedings 59:707-16;755-65, 1984.

Hill, R.M., and Stern, S. Drugs in pregnancy: Effects on the fetus and newborn.Drugs 17:182-97, 1979.

Hingson, R., et al. Effects of maternal drinking and marijuana use on fetal growthand development. Pediatrics 70(4):539-46, 1982.

Hoefel, O.S. Smoking: An important factor in vitamin C deficiency. InternationalJournal for Vitamin and Nutrition Research Supplement 24:121-24, 1983.

Householder, J.; Hatcher, R.; Burns, W.J.; and Chasnoff, I.J. Infants born tonarcotic-addicted mothers. Psychological Bulletin 92:453-468, 1982.

Hutchings, D.E., ed. Prenatal Abuse of Licit and Illicit Drugs: Annals of the NewYork Academy of Sciences. 562, 1989.

Institute of Medicine and National Academy of Sciences. Marijuana and Health.Washington, DC: National Academy of Sciences Press, 1982.

74

Bibliography

Jones, C.L., and Lopez, R.E. Direct and indirect effects on the infant of maternaldrug abuse. In: Hill, G., ed. Public Health Service Report on the Content ofPrenatal Care: Vol. II. Washington, DC: DHHS. In press.

Jordan, R.L.; Young, T.R.; Dinwiddie, S.H.; and Harry, G.J. Phencyclidine-induced morphological and behavioral alterations in the neonatal rat. Phar-macology, Biochemistry, and Behavior 11S:39-45, 1979.

Kaufman, K.R.; Petrucha, R.A.; and Pitts, F.N. Phencyclidine in amniotic fluid andbreast milk: A case report. Journal of Clinical Psychiatry 44:269-270, 1983.

Kleinman, J.C., and Madans, J.H. The effects of maternal smoking, physicalstature, and educational attainment on the incidence of low birth weight.American Journal of Epidemiology 121(6):843-55, 1985.

Kleinman, J.C., et al. The effects of maternal smoking on fetal and infant mortality.American Journal of Epidemiology 127(2): 274-82, 1988.

Klenka, H.M. Babies horn in a district general hospital to mothers taking heroin.British Medical Journal 293:745-46, 1986.

Krajewski, K.J. Crack and cocaine: Current medical issues. Texas Medicine 84:48-50, 1988.

Laeng,reid, L., et al. Teratogenic effects of benzodiazepine use during pregnancy.The Journal of Pediatrics 114:126-31, 1989.

Lam, D., and Goldschlager, N. Myocardial injury associated with polysubstanceabuse. American Heart Journal 115:675-680, 1988.

Larsen, J., ed. Drug Exposed Infants and Their Families: Coordinating Responsesof the Legal, Medical and Child Protection System. Washington, DC: TheAmerican Bar Association Center on Children and the Law, 1990.

Lauwers, J., and Woessner, C. Counseling the Nursing Mother. Wayne, NJ: Avery,1983.

Lewis, P.T. Animal tests for teratogenicity: Their relevance to clinical practice. In:Hawkins, D.F., ed. Drugs and Pregnancy. New York: Churchill Livingston,1987.

Liebman, B. Can vitamins prevent birth defects? Nutrition Action Health Letter(Center for Science in the Public Interest) 17(1):8-9, 1990.

Lifschitz, M.H., et al. Factors affecting head growth and intellectual function inchildren of drug addicts. Pediatrics 75(2):269-74, 1985.Little, B.B. Cocaine abuse during pregnancy: Maternal and fetal implications.

Obstetrics and Gynecology 73:157-60, 1989.

75

A

Bibliography

Lyon, A.J. Effect of smoking on breast feeding. Archives of Disease in Children58(5):378-80, May 1983.

MacGregor, S.N., et al. Cocaine use during pregnancy: Adverse perinatal out-come. American Journal of Obstetrics and Gynecology 157:686-90, 1987.

Marks, T.A.; Worthy, W.C.; and Staples, R.E. Teratogenic potential of phencyclid-ine in the mouse. Teratology 1:241-246, 1980.

Martin, J.; Martin, D.C.; and Lund, C.A. Maternal alcohol ingestion and cigarettesmoking and their effects on newborn conditioning. Alcoholism: Clinical andExperimental Research 1:243, 1977.

Martin, T.A., and Bracken, M.B. Association of low birth weight and passive smokeexposure in pregnancy. American Journal of Epidemiology 124(4):633-42,

1986.McKay, S.R. Substance abuse during the childbearing years. In: Bennett, G.;

Vourakis, C.; and Woolf, D.S., eds. Substance Abuse: Pharmacologic, Devel-opmental, and Clinical Perspectives. New York: John Wiley, 1986.

Miller, G. Addicted infants and their mothers. Zero to Three 9(5):21-23, 1989.Mills, J.L., et al. Maternal alcohol consumption and birthwcight: How much

drinking during pregnancy is safe? Journal of the American Medical Associ-ation 252(14):1875-79, 1984.

Misra, A.L.; Pontani, R.B.; and Bartolomeo, J. Persistence of phencyclidine andmetabolites in brain and adipose tissue: Implications for long-lasting behav-ioral effects. Research Communications in Chemical Pathology and Pharma-cology 24:431-445, 1979.

National Institute on Alcohol Abuse and Alcoholism. Identifying the alcohol-abus-int:, obstetric-gynecologic patient: A practical approach, by Sokol, R.J., et al.PreventingFetal Alcohol Effects: A Practical Guide for OblGyn Physicians andNurses. NIAAA pamphlet. Rockville, MD: the Institute, 1982.

National Institute on Alcohol Abuse and Alcoholism. Alcohol and Birth Defects:The Fetal Alcohol Syndrome and Related Disorders, by Pctrakis, P.L. Rock-ville, MD: the Institute, 1987.

National Institute on Alcohol Abuse and Alcoholism. Fetal alcohol syndrome andother effects of alcohol on pregnancy outcome. Sixth Special Report to theU.S. Congress on Alcohol and Health. Rockville, MD: the Institute, 1987.

National Institute on Alcohol Abuse and Alcoholism. Program Strategies for Pre-venting Fetal A lcohol Syndrome andAlcohol-Related Birth Defects. Rockville,MD: the Institute, 1987.

r 76

Bibliography

National Institute on Drug Abuse. Drug Dependence in Pregnancy: Clinical Man-agement of Mother and Child, Finnegan, L.P., ed. NIDA Services ResearchMonograph Series. Rockville, MD: the Institute, 1979.

National Institute on Drug Abuse. Treatment Services for Drug Dependent Women:Vols.I and H, Reed, B.G.; Beschner, G.M.; and Mondonaro, J. eds. NIDATreatment Research Monograph Series, Rockville, MD: the Institute, 1980/82.

National Institute on Drug Abuse. Part II: Effects of methadone on offspring andusers. Research on the Treatment of Narcotics Addiction: State of the Art,Cooper, J.R., et al., eds. NIDA Treatment Research Series. Rockville, MD:the Institute, 1983.

National Institute on Drug Abuse. Marijuana Effects on the Endocrine andReproductive Systems: A RA US Review, Braude, M.C., and Ludford, J.P., eds.NIDA Research Monograph 44. Rockville, MD: the Institute, 1984.

National Institute on Drug Abuse. Current Research on the Consequences ofMaternal Drug Abuse, Pinkert, T.M., ed. NIDA Research Monograph 59.Rockville, MD: the Institute, 1985.

National Institute on Drug Abuse. Opioids and development: New lessons fromold problems, by Zagon, I.S. In: Chiang, C.N., and Lee, C.C., eds. PrenatalDrug Exposure: Kinetics and Dynamics. NIDA Research Monograph 60.Rockville, MD: the Institute, 1985.

National Institute on Drug Abuse. Phencyclidine: An Update , by Clouet, D., ed.NIDA Research Monograph 64. Rockville, MD: the Institute, 1986.

National Institute on Drug Abuse. Cocaine abuse. NIDA Capsule CAP05, Rock-ville, MD: the Institute, 1986.

National Institute on Drug Abuse. Effect of maternally administered opiates onthe development of the beta-endorphin system in the offspring, byGianoulakis, C. In: Progress in Opioid Research: Proceedings of the 1986International Narcotics Research Conference, NIDA Research Monograph75, Rockville, MD: the Institute, 1987.

National Institute on Drug Abuse. Drug Abuse and Drug Abuse Research: TheSecond Triennial Report to Congress. Rockville, MD: the Institute, 1987.

National Institute on Drug Abuse. Drug abuse and pregnancy. NIDA CapsuleC-89-04, Rockville, NI t.): the Institute, 1989.

National Institute on Drug Abuse. Management of maternal and neonatal sub-stance abuse problems, by Finnegan, L.P. In: Harris, L.D., ed. Problems ofDrug Dependence. NIDA Research Monograph 95, Rockville, MD: theInstitute, 1989.

77

Bibliography

Nelson, L.B., et al. Occurrence of strabismus in infants born to drug-dependentwomen. American Journal of Diseases and Children 141:175-78, 1987.

Nicholas, J.M.; Lipshitz, J.; and Schreiber, E.C. Phencyclidine: Its transfer acrossthe placenta as well as into breast milk. American Journal of Obstetrics andGynecology 143:143-146, 1982.

O'Brien, C.P.; Childress, A.R.; Arndt, I.O.; McLellan, A.T.; et al. Pharmacologicaland behavioral treatments of cocaine dependence: Control studies. Journalof Clinical Psychiatry 49(2):Supp1.17-22, 1988.

Office for Substance Abuse Prevention. Drug survey reveals good news, bad news.Prevention Pipeline 2(5):1-2, 1989.

Office of National Drug Control Policy. The 1990 National Drug Control Strategy.Washington, DC: The White House, 1990.

Office on Smoking and Health. The Health Consequences of Smoking for Women:A Report of the Surgeon General, Rockville, MD: the Office, 1980.

Office on Smoking and Health. Smoking Tobacco and Health: A Fact Book.Rockville, MD: the Office, 1987. (Revised 10/89).

Office on Smoking and Health. Reducing the Health Consequences of Smoking: 25Years of Progress A Report of the Surgeon General. Rockville, MD: theOffice, 1989.

Oro, A.S., and Dixon, S.D. Perinatal cocaine and methamphetamine exposure:Maternal and neonatal correlates. Journal of Pediatrics 111(4):571-78, 1987.

Ostrea, E.M., and Chavez, C.J. Perinatal problems (excluding neonatal with-drawal) in maternal drug addiction: A study of 830 cases. Journal of Pediatrics94:292-95, 1979.

Perlmutter, J.F. Heroin addiction and pregnancy. Obstetrics and Gynecology Sur-veys 29:439-446, 1974.

Prager, K.; Malin, H.; Spiegler, D.; et al. Smoking and drinking behavior beforeand during pregnancy of married mothers of liveborn and stillborn infants.Public Health Reports 99(2):117-127, 1984.

Public Health Service. The Health Consequences of Involuntary Smoking. A Reportof the Surgeon General. P.ockville, MD: DHHS, 1986.

Public Health Service. Healthy People 2000: National Health Promotion and Dis-ease Prevention Objectives. Washington: DC: PHS, 1990.

Rosen, M.G. (panel chairman). Caring for Our Future: The Content of PrenatalCare. A Report of the Public Health Service Expert Panel on the Content ofPrenatal Care. Washington, DC: PHS, 1989.

78

Bibliography

Rosett, H.L., and Weiner, L. Identification and Prevention of Fetal Alcohol Syn-drome (brochure). Brookline, MA: Boston University School of Medicine,1980.

Rosett, H.L., and Weiner, L. Alcohol and the Fetus: A Clinical Perspective. NewYork: Oxford University Press, 1984.

Rubin, D.A., et. al. Effect of passive smoking on birth weight. Lancet 2:415-47,1986.

Russell, M. Alcohol abuse and alcoholism in the pregnant woman: Identificationand intervention. Alcohol Health and Research World 10: 28-31,74, 1985.

Russell, M., and Coviello, D. Heavy drinking and regular psychoactive drug useamong gynecological outpatients. Alcoholism: Clinical and ExperimentalResearch 12(3):400-406, 1988.

Russell, M., and Skinner, J.B. Early measures of maternal alcohol raisu,,e aspredictors of adverse pregnancy outcomes. Alcoholism: Clinical and Exper-imental Research 12(6):824-30, 1988.

Russell, M. "Development of the "TWEAK" Test for Female Problem Drinkers."Presentation at Children's Hospital, Buffalo, NY, Feb. 1989.

Scher, M.S., et al. The effects of prenatal alcohol and marijuana exposure: Distur-bances in neonatal sleep cycling and arousal. Pediatric Research 24(1):101-5,1988.

Schneider, J. "Assessment of Infant Motor DevJopments." Presentation atNAPARE conference in New York City, Aug. 30, 1988.

Shiono, P.H., et al. Smoking and drinking during pregnancy. Journal of the Amer-ican Medical Association 255(0:82-84, 1986.

Silverman, S. Scope. specifics of maternal drug use, and effects on fetus arebeginning to emerge from studies. Journal of the American Medical Associa-tion 261(12):1688-89, 1989.

Strauss, A.A.; Modanlou, D.; and Bosu, S.K. Neonatal manifestations of maternalphencyclidine (PCP) abuse. Pediatrics 68:550-52, 1981

Streissguth, A.P. Developmental neurotoxicity of alcohol: State of the research andimplications for public policy and future directions. In: Melton, G.;Sonderregger, T.; and Schroeder, S., eds. Behavioral Toxicology of Childhoodand Adolescence. Lincoln, NE: University of Nebraska Press, 1989.

Streissguth, A.P., Barr, H.M.; Sampson, P.D.; Darby, B.L.; and Martin, D.C. IQat age 4 in relation to maternal alcohol use and smoking during pregnancy.Developmental Psychology 25:3-11, 1989.

The cocaine-AIDS connection. Science News 134:27, 1988

79

J

Bibliography

The Physicians' Desk Reference (PDR). Edition 43, Oradell, NJ: Medical Econom-ics, 1989.

Ward, S.L., et al. Abnormal sleeping ventilatory pattern in infants of substance-abusing mothers. American Journal of Disabled Children 140(10):1015-20,1986.

Warren, K. Alcohol-related birth defects: Current trends in research. AlcoholHealth and Research World 10(1):4-5,71, 1985.

Werler, M.M., et al. Smoking and pregnancy. Teratology 32:473-481, 1985.Wilson, G.S.; Desmond, M.M.; and Verniaud, W.M. Early development of infants

of heroin-addicted mothers. American Journal of Diseases of Children126:457-462, 1973.

Woods, J.R., et al. Effect of cocaine on uterine blood flow and fetal oxygenation.Journal of the American Medical Association 257:957-61, 1987.

Zacharias, J. A rational approach to drug use in pregnancy. Journal of Obstetnc,Gynecologic, and Neonatal Nursing 12(3):183-87, 1983.

Zelson, C.; Kahn, E.J.; Neumann, L.; and Polk, G. Heroin withdrawal syndrome.Journal of Pediatrics 76:483, 1970.

Zuckerman, B.; Frank, D.A.; Hingson, R.; et al. Effects of maternal marijuana andcocaine use on fetal growth. New England Journal of Medicine 320(7):762-768, 1989.

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OSAPReprinted by the Office for Substance Abuse Prevention

and distributed by OSAP'sNational Clearinghouse for Alcohol and Drug Information

P.O. Box 2345Rockville, MD 20847-2345

1-800-729-6686in Maryland and D.C. Metro Area call:

301-468-2600

El 7

Contents

ForewordIntroduction

Extent of the ProblemThe Purpose of This Booklet

Changing Perspectives onTeratologyMultiple Maternal Factors Influence Pregnancy OutcomesCharacteristics of Drugs and the Fetus Affect Risk

Genetic Vulnerability of the FetusTiming of Drug ExposureDosage and Patterns of ConsumptionChemical Properties of the Drug

Teratogenic Research Has Many Limitations

Animal ResearchResearch With HumansMethodological Problems

Hazards of Prenatal Exposure to Alcohol, Tobacco, and Other Drugs .

AlcoholTobaccoMarijuanaCocaineHeroin and Other Opioids or Synthetic Narcotics

PhencyclidinePrescription Medications and Other Licit Substances


SummaryFor More Information

Selected Health Information ClearinghousesCompendiums of ResourcesPublications and PamphletsHelp With Treatment ReferralsRecommended For Further Reading

Bibliography

DHHS Publication No. (AD1v1)92-1711Printed 1990. Reprinted 1992.

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