Substance Use Disorder in Pregnancy

Substance use disorder is a chronic medical illness affecting many pregnant women. The neurobiology of addiction is predominantly rooted in dopaminergic pathways and can be conceptualized as a reward deficit disorder mediated by both positive and negative reinforcement. All pregnant women should be screened for substance use. Screening, brief intervention, and referral to treatment are the guiding principles of pregnancy care for women with substance use disorder. For women diagnosed with substance use disorder, motivational interviewing can be used to determine desire for behavioral change (e.g., readiness for treatment). Multidisciplinary care is essential. Treatment is typically a combination of cognitive behavioral therapy and medication-assisted treatment, especially among women with opioid use disorder. Medication-assisted therapy with buprenorphine or methadone for women with opioid use disorder reduces the chance of relapse and improves ongoing engagement in treatment. However, medication-assisted therapy is not available for many drugs of abuse, such as stimulants and cannabis. Regardless of treatment options, relapse is part of the chronic disease process, and it should not be considered detrimental to the provider-patient relationship. Substance use has been associated with a number of adverse pregnancy outcomes; the risks to the mother and fetus are somewhat variable, depending on the drug of dependence. Specific drugs of abuse and the available evidence regarding maternal and fetal effects during pregnancy are reviewed in the chapter, as well as neonatal effects during lactation. Obstetricians play a critical role in caring for women with substance use disorder in a nonjudgmental, trauma-informed manner to optimize pregnancy outcomes.