A Look at Pregnancy and Wellness

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From the moment of conception, the health of an unborn child and its mother are inextricably linked. Decades ago, scientists thought that the placenta protected the developing baby from any toxins in the mother’s bloodstream during pregnancy. Today, they know that the placenta is highly permeable, with many drugs and their metabolites being able to cross from the mother’s bloodstream into her baby’s.This means that if the mother uses a drug, then so does her baby. Some substances, such as alcohol, are safe for many adults to use in moderation. But for a developing child, even a small amount can cause major and widespread changes. It doesn’t yet have a fully developed liver or metabolism, so it is unable to properly process the drugs once they enter its body. Once there, the drugs act as toxins to damage and interfere with the development of the child’s heart, lungs, brain, and other organs.

These changes are most severe during the first trimester of pregnancy. During this time, the baby’s brain has to grow from just a handful of cells into the framework of a nervous system, comprised of billions of cells.[1] Each nerve cell has to mature into the right shape, migrate into position, and wire up connections to up to 10,000 other cells.[2] For this to happen properly, each cell must be guided by a myriad of genes, hormones, and signaling chemicals. Using drugs interferes with this process, causing some nerve cells to grow incorrectly, wire up poorly, or die.

The impact of a drug on a developing child will vary depending on what drug the mother uses and how much of it is used. The effects on the child can range from subtle, like causing difficulty paying attention in class in grade school, to possibly disabling, like mental retardation.

Despite this, many women still use drugs while they’re pregnant. The Substance Abuse and Mental Health Services Administration (SAMHSA) found that in the past month, 8.5 percent of pregnant women aged 15 to 44 had used alcohol, 15.9 percent had smoked cigarettes, and 5.9 percent had used illegal drugs.[3] According to estimates, approximately 400,000[4] children are exposed to tobacco in utero and 225,000[5] are exposed to illegal drugs every year. In addition, each year sees about 40,000[6] cases of fetal alcohol spectrum disorders (FASD) from a much larger number of alcohol exposures.

Why Do Pregnant Women Use Drugs?

It can be hard to understand why pregnant women might continue to use substances that harm their unborn children. There are a number of reasons why this might be the case.

  • They don’t yet know that they’re pregnant. Although for some women, pregnancy makes itself known in symptoms like morning sickness and missed periods, many women don’t know that they’re pregnant for weeks or months after conception. They might continue to use drugs in this time period, although once most women find out they’re pregnant, they quit using drugs. Women who are pregnant use alcohol, tobacco, and marijuana at much lower rates than women who aren’t pregnant, and rates of use drop off sharply from the first trimester to the second.[7]
  • They’re self-medicating a mental illness or trauma. Many people who experience substance abuse are using drugs to self-medicate an underlying condition. Even if they want to quit once they get pregnant, their mental illness or past trauma can drive them to keep using. One study found that among pregnant women entering a treatment program for drug abuse, 73 percent had suffered physical abuse at some point in their lifetimes, 71 percent had suffered emotional abuse, 45 percent had suffered sexual abuse, and 36 percent had suffered all three.[8]
  • They believe that using just a little is okay or hold other misconceptions. A study on alcohol and pregnancy found that these types of harmful beliefs can include:[9]
    • Some types of alcohol are safe to drink during pregnancy.
    • Drinking during the third trimester doesn’t harm the child.
    • Small amounts of alcohol are okay (some women reported that their doctors confirmed this).

Pregnancy and Alcohol

Alcohol use is widespread in the United States. About half of Americans over the age of 12 drank alcohol in 2012, nearly one-quarter binge drank in the last month, and about one in fifteen were heavy drinkers.[10]

When a pregnant woman consumes alcohol, it crosses the placenta to affect her developing child. Because the fetus can’t metabolize alcohol properly, its blood alcohol level (BAC) will stay higher for longer and toxic metabolites of alcohol will also stay in its bloodstream longer. The alcohol can kill the most sensitive cells (such as in the brain) and cause others to grow incorrectly. Alcohol also constricts the blood vessels in the placenta, restricting blood flow and the supply of oxygen and nutrients to the fetus.[11] If this restriction is severe enough, the result can be miscarriage.

If the child survives, the systemic damage places the child at risk for developing a fetal alcohol spectrum disorder (FASD). At its most extreme, FASD can cause mental retardation, making prenatal alcohol exposure the most common preventable non-genetic cause of intellectual disability.[12],[13] Up to one percent of the population may be affected by FASD.[14],[15]

The most severe form of FASD is fetal alcohol syndrome (FAS). Its symptoms can include:

  • Low birth weight
  • Heart, lung or kidney defects
  • Vision or hearing problems
  • Abnormal facial features
  • Impaired cognitive abilities
  • Learning disabilities
  • Behavioral problems, such as hyperactivity and impulsiveness
  • Attention and memory problems
  • Poor impulse control or judgment

Less-severe manifestations of FASD can have any number of the above symptoms and can go by a variety of names, including:

  • Alcohol-related neurodevelopmental disorder (ARND)
  • Alcohol-related birth defects (ARBD)
  • Fetal alcohol effects (FAE)
  • Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)
  • Partial fetal alcohol syndrome (pFAS)

Children with FAS incur nine times the health care costs of children without any type of FASD, and they can cost up to $2 million to care for over a lifetime.[16] FASD altogether costs the US health care system over $6 billion annually.[17]

In one study, people with FASD aged six to 51 had the following difficulties:[18]

  • 94 percent experienced problems with mental health
  • 83 percent of adults were unable to live independently
  • 79 percent of adults had difficulty with employment
  • 60 percent of those aged 12 and up had experienced legal troubles
  • 50 percent were admitted for inpatient treatment for mental health issues or substance abuse, or were incarcerated
  • 43 percent had trouble with school
  • 35 percent had problems with drugs and alcohol

According to the US Surgeon General, no amount of alcohol is safe to consume during pregnancy.[19] If a woman finds out that she is pregnant and has consumed alcohol, ceasing alcohol use immediately can help limit the damage. With nearly half of all births in the United States being unplanned, women who are of childbearing age and who are sexually active should work with their doctors to reduce the likelihood that drinking will overlap with pregnancy.[20]

Tobacco, Nicotine and the Developing Child

Although tobacco isn’t as popular as alcohol, its use is still widespread – about a quarter of Americans aged 12 or older used tobacco products in 2012.[21]

Only about half of women who smoke cigarettes quit smoking while they are pregnant.[22] Children whose mothers don’t quit are exposed to over 4,000 chemicals found in tobacco as well as the carcinogens and carbon monoxide generated by burning plant matter.[23] Although nicotine replacement products like the nicotine patch and e-cigarettes don’t contain carbon monoxide, they still contain nicotine.

Like alcohol, nicotine and its metabolites act as a vasoconstrictor. Nicotine constricts the blood vessels in the placenta and reduces blood flow by as much as 38 percent.[24] Starving the fetus of oxygen and nutrients can cause low birth weight, pregnancy complications, and premature delivery, and it increases the risk for miscarriage and ectopic pregnancy.[25] The nicotine, its metabolites, and other toxins also damage the baby’s lungs and brain, resulting in the risk for reduced lung capacity and behavioral problems later in life. Exposed children are also more likely to have a cleft palate.

About 20 to 30 percent of all low birth weight infants were affected by in utero smoking exposure,[26] and the cost of caring for these children comes to over $350 million per year.[27] Once born, the infants are at substantially greater risk for sudden infant death syndrome (SIDS). In fact, smoking more than 20 cigarettes a day during pregnancy causes the likelihood of SIDS to go up fivefold.[28] As they grow up, these children are also at greater risk for developing ADHD, conduct disorder, and obesity, and as teenagers and adults, they’re more likely to be dependent on nicotine themselves.[29]

The more a pregnant woman smokes, the stronger the effects of the tobacco are on the child. Although nicotine replacement products are not safe to use during pregnancy as they still expose the child to nicotine, they do eliminate the carbon monoxide and some of the other byproducts of smoking.[30] For women who are unable to quit smoking, using a nicotine replacement might enable them to limit the amount of damage to the fetus, as well as to reduce the overall dose of nicotine they’re taking (most nicotine replacements equal about 10 cigarettes a day).[31] Women who smoke and are considering becoming pregnant, or who are already pregnant, should work with their doctor to find the best solution to help protect their child.

Illegal Drugs and Pregnancy: Marijuana

Marijuana contains hundreds of chemicals, but the one responsible for most of its active effects is tetrahydrocannabinol (THC). This drug acts in the brain by mimicking the effects of endocannabinoids, types of signaling molecule that nerve cells use to communicate.

One study found that endocannabinoids are one of the factors responsible for guiding a growing fetus’s nerve cells to grow into the correct positions and to wire to each other properly.[32] THC interferes with this process. In the study, fetuses donated by marijuana-smoking mothers displayed nerve endings that were stunted and bundled incorrectly. They had lower body weights and lower levels of a protein called stathmin-2, which is involved in learning and memory formation.

In the long term, prenatal marijuana exposure can have a variety of possible effects on children, which can last through young adulthood:[33]

  • Impairments in problem-solving abilities
  • Memory problems
  • Difficulty planning
  • Impulsivity
  • Attention problems
  • Depression
  • Increased likelihood of using tobacco or marijuana

Illegal Drugs and Pregnancy: Cocaine

During the crack epidemic of the 1980s and 1990s, a series of reports came out describing babies that had been exposed to cocaine in utero as severely damaged. At the height of the epidemic, about 100,000 children were exposed to cocaine during pregnancy each year.[34] According to the reports, the babies were undersized with wrinkled, greyish skin, tremors, and weak limbs, and they were destined to develop severe social and intellectual disabilities.

Today, we know that these reports of the effects of cocaine may have been exaggerated. But cocaine exposure still does affect babies and in ways that are far more subtle.

Babies exposed to cocaine in the womb are more likely to have low birth weight, smaller head size, and shorter birth length.[35] As they grow up, they’re more likely to have an overlapping array of small deficits in intelligence, language skills, attention, organization, self-control, and abstract thinking.[36]

Illegal Drugs and Pregnancy: Methamphetamine

Less longitudinal data exists on outcomes for children exposed solely to methamphetamines, both due to the small number of studies and the fact that mothers who use methamphetamines may also use other drugs as well. However, some evidence exists so far that methamphetamine exposure can result in increased risk of:

  • Premature delivery
  • Detachment of the placenta from the uterus
  • Low birth weight
  • Problems with sleep and wakefulness
  • Heart and brain defects
  • Attention impairments[37]

Illegal Drugs and Pregnancy: Heroin

If a pregnant woman uses heroin regularly, her baby will develop heroin dependence alongside its mother. Once addicted, if the mother’s daily heroin use fluctuates, the baby cycles through spikes and withdrawal. If the mother quits suddenly, then the baby goes through fetal abstinence syndrome, which increases the likelihood of stillbirth, premature delivery, low birth weight, and SIDS.[38]

When the baby is born, getting cut off from the supply of heroin from the mother causes neonatal abstinence syndrome (NAS), which can cause:

  • Excessive crying
  • Fever
  • Irritability
  • Tremors
  • Diarrhea
  • Vomiting
  • Slow weight gain
  • Seizures
  • Death[39]

To prevent NAS, heroin-using mothers can seek methadone or buprenorphine treatment. This stabilizes their opiate exposure and gets them onto a lower dose of opiates. When the baby is born, it can be treated with medications like morphine or buprenorphine to gradually and safely taper it off opiates.

A Little Bit of Prevention Goes a Long Way

There is no safe level of use of alcohol, cigarettes or drugs while pregnant. Although it may be difficult, complete abstinence from substance use is the only way to ensure your baby will be protected. If you’re a substance user who is pregnant or considering getting pregnant, we can help you quit or find strategies to minimize your use and protect your child. Call us to learn more.

Citations

[1] Samuelsen, G.B., Larsen, K.B., Bogdanovic,N., Laursen, H., Graem, N., Larsen, J.F., and Pakkenberg, B. (2003). “The Changing Number of Cells in the Human Fetal Forebrain and its Subdivisions: A Stereological Analysis.” Cerebral Cortex. Accessed September 10, 2014.

[2] Byrne, J.H. (n/a) “Introduction to Neurons and Neuronal Networks.” University of Texas Medical School at Houston. Accessed September 8, 2014.

[3] “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” (2013). Substance Abuse and Mental Health Services Administration. Accessed September 8, 2014.

[4] Rehan, V.K., Liu, J., Naeem, E., Tian, J., Sakurai, R., Kwong, K., Akbari, O., and Torday, J.S. (October 30, 2012). “Perinatal nicotine exposure induces asthma in second generation offspring.” BioMed Central Medicine. Accessed September 9, 2014.

[5] Keegan, J., Parva, M., Finnegan, M., Gerson, A., and Belden, M. (April 29, 2010). “Addiction in pregnancy.” Journal of Addictive Diseases. Accessed September 8, 2014.

[6] “About FASD.” (August 29, 2014). Substance Abuse and Mental Health Services Administration. Accessed September 8, 2014.

[7] “The NSDUH Report: Substance Use among Women During Pregnancy and Following Childbirth.” (May 21, 2009). Substance Abuse and Mental Health Services Administration. Accessed September 8, 2014.

[8] Velez, M.L., Montoya, I.D., and Campbell, J. (January 2006). “Exposure to violence among substance-dependent pregnant women and their children.” Journal of Substance Abuse Treatment. Accessed September 9, 2014.

[9] Elek, E., Harris, S.L., Squire, C.M., Margolis, M., Weber, M.K., Dang, E.P., and Mitchell, B. (June 28, 2013). “Women’s Knowledge, Views, and Experiences Regarding Alcohol Use and Pregnancy: Opportunities to Improve Health Messages.” American Journal of Health Education. Accessed September 9, 2014.

[10] “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” (2013). Substance Abuse and Mental Health Services Administration. Accessed September 10, 2014.

[11] “Effects of Alcohol on a Fetus.” (2007). Substance Abuse and Mental Health Services Administration. Accessed September 10, 2014.

[12] Lester, B.M., Andreozzi, L., and Appiah, L. (April 20, 2004). “Substance use during pregnancy: time for policy to catch up with research.” Harm Reduction Journal. Accessed September 10, 2014.

[13] “FASD: What Everyone Should Know.” (n/a). National Organization on Fetal Alcohol Syndrome. Accessed September 10, 2014.

[14] Wattendorf, D.J. and Muenke, M. n (July 15, 2005). “Fetal Alcohol Spectrum Disorders.” American Family Physician. Accessed September 10, 2014.

[15] “Frequently Asked Questions about FASD.” (August 29, 2014). Substance Abuse and Mental Health Services Administration. Accessed September 10, 2014.

[16] “About FASD.” (August 29, 2014). Centers for Disease Control and Prevention. Accessed September 10, 2014.

[17] Ibid.

[18] “Fetal Alcohol Spectrum Disorders By the Numbers.” (January 2006). Substance Abuse and Mental Health Services Administration. Accessed September 10, 2014.

[19] U.S. Surgeon General. (2005) “A 2005 Message to Women from the U.S. Surgeon General: Advisory on Alcohol Use in Pregnancy.” Centers for Disease Control and Prevention. Accessed September 10, 2014.

[20] Ibid.

[21] “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” (2013). Substance Abuse and Mental Health Services Administration. Accessed September 10, 2014.

[22] “The NSDUH Report: Substance Use among Women During Pregnancy and Following Childbirth.” (May 21, 2009). Substance Abuse and Mental Health Services Administration. Accessed September 10, 2014.

[23] Lester, B.M., Andreozzi, L., and Appiah, L. (April 20, 2004). “Substance use during pregnancy: time for policy to catch up with research.” Harm Reduction Journal. Accessed September 10, 2014.

[24] Ibid.

[25] Wickstrom, R. (September 2007). “Effects of Nicotine During Pregnancy: Human and Experimental Evidence.” Current Neuropharmacology. Accessed September 10, 2014.

[26] Lester, B.M., Andreozzi, L., and Appiah, L. (April 20, 2004). “Substance use during pregnancy: time for policy to catch up with research.” Harm Reduction Journal. Accessed September 10, 2014.

[27] “Smoking and Pregnancy— What Are the Risks?” (July 2012). National Institute on Drug Abuse. Accessed September 10, 2014.

[28] Wickstrom, R. (September 2007). “Effects of Nicotine During Pregnancy: Human and Experimental Evidence.” Current Neuropharmacology. Accessed September 10, 2014.

[29] Ibid.

[30] “Tobacco, Alcohol, Drugs, and Pregnancy.” (December 2013). American College of Obstetricians and Gynecologists. Accessed September 10, 2014.

[31] Bruin, J.E., Gerstein, H.C., and Holloway, A.C. (March 25, 2010). “Long-Term Consequences of Fetal and Neonatal Nicotine Exposure: A Critical Review.” Toxicological Sciences. Accessed September 10, 2014.

[32] Tortoriello, G., Morris, C.V., Alpar, A., Fuzik, J., Shirran, S.L., Calvigioni, D., Keimpema, E., Botting, C.H., Reinecke, K., Herdegen, T., Courtney, M., Hurd, Y.L., and Harkany, T. (January 27, 2014). “Miswiring the brain: Δ9‐tetrahydrocannabinol disrupts cortical development by inducing an SCG10/stathmin‐2 degradation pathway.” The EMBO Journal. Accessed September 10, 2014.

[33] Minnes, S., Lang, A., and Singer, L. (July 2011). “Prenatal Tobacco, Marijuana, Stimulant, and Opiate Exposure: Outcomes and Practice Implications.” Addiction Science & Clinical Practice. Accessed September 10, 2014.

[34] Ibid.

[35] “What are the effects of maternal cocaine use?” (September 2010). National Institute on Drug Abuse. Accessed September 10, 2014.

[36] Lester, B.M., Andreozzi, L., and Appiah, L. (April 20, 2004). “Substance use during pregnancy: time for policy to catch up with research.” Harm Reduction Journal. Accessed September 10, 2014.

[37] “What are the risks of methamphetamine abuse during pregnancy?” (September 2013). National Institute on Drug Abuse. Accessed September 10, 2014.

[38] Minnes, S., Lang, A., and Singer, L. (July 2011). “Prenatal Tobacco, Marijuana, Stimulant, and Opiate Exposure: Outcomes and Practice Implications.” Addiction Science & Clinical Practice. Accessed September 10, 2014.

[39] “How does heroin use affect pregnant women?” (February 2014). National Institute on Drug Abuse. Accessed September 10, 2014.

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