Virtually all illegal drugs, such as heroin and cocaine, pose dangers to a pregnant woman. Legal substances, such as alcohol and tobacco, are also dangerous, and even medical drugs, both prescription and over-the-counter, can be harmful. For her own health and the health of her baby-to-be, a woman should avoid all of them as much as possible, from the time she first plans to become pregnant or learns that she is pregnant. 
Nearly 4 percent of pregnant women in the United States use illicit drugs such as marijuana, cocaine, and other amphetamines, and heroin. These and other illicit drugs may pose various risks for pregnant women and their babies. 
I have chosen three scientific articles that discuss the issues of substance abuse during and after pregnancy and possible adverse reactions connected to it.
Article no 1: Management of women who use drugs during pregnancy
The artice published by Department of Obstetrics and Gynaecology in Leeds in UK pinpoints that illicit substance missuseis increasing in society and that maternity sercives should pay more attention in providing good care connected to this specific problem. Even though this article discusses a lot of management of such women problems which is not the topic of this term paper, the article also includes sertain pharmacological and toxicological information which is of interest for us.
Maternal health and fetal damage
The drugs can have an influence of maternal and baby health, but there are plenty of other factors which affect it: poor social environment, nutrition, hygiene, sexual exploitation. Reproductive disruption associated with heroin use has been demonstrated in both men and women and even low doses of narcotics can impair normal ovarian function and ovulation  . This impacts on conception and on dating of the pregnancy.
The concomitant malnutrition that can acompany illicit drug use might have a greater effect than substance misuse on both reproduction and pregnancy.
The damage that accompanies substance use comes either directly from the efect of the drug itself or from problems related to growth and /or premature delivery. The complications of confounding factors – chaotic lifestyle, poor nutrition, alcohol use and cigarette smoking –affect the assessment of the effects of cocaine in pregnancy. In obstetric practice, 100% of pregnant women using cocaine or heroin are cigarette smokers. Cigarette smoking is probably the most common form of substance use and is significant concomitant factor in women who use illegal drugs. Babies whose mothers smoked in pregnancy tend to have lower birth weights and reduced lenght, cranial and thoracic measurements at birth  .
Cocaine is a vasoactive drug and, as such, can cause specific problems to the baby secondary placental damage and by direct fetal vascular effects . There is no specific syndrome or cluster of signs and the effects associated with it. Poor fetal growth and premature delivery are significant problems in all types of drug and alcohol use.
Materials and methods
The best form of intervention is cessation to use. However, for a variety factors many women who use drugs present late, and often after the crucual first few weks of embryo development. Therefore, care during pregnancy is based on harm reduction.
In case of heroin, substitution treatment options are avalable to help in this process.
Since the introduction of methadone programs, a drug used as a replacement for heroin, treatment of heroin addiction while pregnant has been controversial. Some are concerned with higher occurrence of complications and greater severity of withdrawal symptoms upon birth, while others support the treatment. If a mother stops using the drug "cold turkey," the fetus will then experience withdrawal symptoms in the womb, with may cause wide swings in the baby's blood level from intoxication to withdrawal, which often times leads to death and spontaneous abortion, premature birth, and other negative effects. 
Buprenorphine has been successfully used outside of pregnancy, and there is emerging evidence to suggest that children born to motherswho are maintained on buprenorphine are at lower risk of neonatal abstinence syndrome (NAS)
Randomised controled trials have now been carried out to look at the difference in outcome between buprenorphine and methdione. Although numbers in these studies are small, Jones et al. Found that peak NAS total scores did not differ significantly betwen groups and their results suggest that buprenorphene is not inferior to methadione on outcome measures assessing NAS and maternal and neonatal safetly when started in the seco d trimester.
From this article we could conclude that substance abuse in pregnancy is highly asocciated with maternal and fetal morbidity. Supportive environment should be provided for expecting mother to minimise the risk, not only during prgegnancy but also during neonatal period and in long therm. Expectant mothers should if possible cease to use the drugs but many fail todo so. In case of cocaine abuse certain pharmacological interventions could be taken, for example, substituting cocaine with buprenorphine or methadione, that according the trials showed no significant differences in the effect.
Article No 2: Substance abuse during pregnancy: effect on pregnancy outcomes
As substance use during pregnancy continues to be a major problem, a retrospective cohort study of 247 drug-using women and 741 controls was made in UK in the period of 4 years:1997-2000. Preterm labour, miscarriage, abruption and postpartum haemorrhe are the obstetric complications which have been asociated with women who are dependent on opiates. Fetal effects include intrauterine growth restriction, prematurity, stillbirth and neonatal abstinence syndrome. Women frequently ask to what extent th erisk to their baby is influenced by their drug ‘habit‘ alone and within this servise model there was conducted a retrosepctive cohort study to etermine the contribution of drug use to maternal and perinatal complications, attempting to control for ‘social‘ cofounders. 
Material and methods
In this study 247 cases of drug-using women were identified from the drug depenency register. A woman was considered a drug user if she had self-reported use of methadone, heroin, cocaine or any other drug of addiction at any time during pregnancy. Confirmation of drug history was checked by taking urine samples. Three controls (for whom no history of drug use was recorded) were selected from the delivery suite reocrds and matched with each woman with substance abuse. Calliper matching was done by district of residence and year of delivery, so that any control patient who delivered within 6 months before or after the date of delivery of a drug using woman was considered as a potential match.
The multidisciplinary model involves a co-ordinated prigramme of care betwen hospital services and drug agencies working with drug misusers. The control group had the usual UK model of care shared between primary care and hospital specialist services.
The following information was extracted from computerised medical records and the drug history register:demographic details,smoking, past and present drug history, and current antenatal problems. The information in drug history register is recorded byt the specialist midwife. Smoking history was clasified into four groups:none, 1-10, 11-20, and less than 20 cigarettes a day. Dosage of the drug methadone in each trimester was recorded. Delivery details included gestation at delivery, duration of labour, onset of labour and mode of delivery. The neonatal data recorded were birth weight, umbilical artery cord pH, Apgar scores, admission to the neonatal unit and perinatal death. The primary preterm birth, abruption, pre-eclampsia, intrauterine growth restriction and low birth weight.the WHO criterion of birth weight less than 2500 g was used to define low birth weight. Intrauterine growth restriction was defined as a birth weight less than the 3rd centile for gestation.
Data were recorded in a pre-designed data sheet and entered into a database.Analysis was caried out using Stata (version 8.2). A univariate analysis was initially performed to examine the baseline characteristics of the drug users and controls, using Pearson`s Chi-squared test or Fisher`s exact test or Fisher`s exact test to compare the profiles od categorical explanatory variables betwen drug uses and controls. The two-sample t-test or mann-Whitney test were used for normally distributed and skewed continuous variables accordingly. Instead of matching was adjusted for by adding deprivation score and year of delivery into the Poisson model.Other potentially confounding variables, namely age, parity and smoking were also adjusted for the Poisson regression.
There were 247 cases and 741 controls (as three matched controls were obtained for each case). Thee were significantly more multiparous women in the drug user group than compared to controls.
The most common drug used was methadione, primarily as a result of of the methadone substitution programme. A very small number of drug users (3/247, 1,4%) who were taking methadone at booking were no longer taking it at delivery. The majority of women on methadone also used other substances during pregnancy (155/214, 72,4%). The common drugs were heroin 66.8%, cocaine 63.2% and benzodiazepines11.3%. Approximately half of the drug dependent women used intravenous drugs during pregnancy (122/238, 51.3%). Drug users were significantly more likely to smoke cigarettes than controls. (97.6% vs 34.1%) and the proportion of drug users who smoked more than 10 cigarettes per day was significantly higher compared to controls (64.8% vs. 5.9%).
There were no statistically or clinically important differences with regard to onset of labour and mode of delivery between the groups, but gestation birth was on average shorter b 10 days in the drug-using group. There were no significant differences in the immediate neonatal outcome with regard to Apgar score (RR= 1.83, 95% CI 0.9-3.70) or cord pH where available (RR 0.66, 75% CI= 0.30- 1.46)
The proportions of women experiencing each of the primary and secondary outcomes along the relative risks between the two groups obtained from Poisson regression adjusted for confounding factors.
There was a statistically significantly greater proportion of preterm births amongst drug-using women compared to controls (25% of preterm births among drug-using women. The incidence of low birth weight as 30.8% amongst the drug-using women compared to 8% in control group and the incidence of growth restriction was 25 %, significantly higher than in the control group.
The relative risk of preterm birth appears consistent amongst the group of different drug users, but the risk of abruption is least in women using methadone and highest in those using cocaine.
Comparisons of outcomes between the different groups of drug-users (methadone alone vs. multiple use, heroine alone vs. multiple use, cocaine vs. non-cocaine use) for the primary outcomes of interest did not show any statistically significant differences.
The numbers in the individual drug use groups are to small for reasonable comparisons between these groups.
Drug use during pregnancy appears to carry an increased risk of preterm birth, fetal growth restriction and placental abruption compared with women from similar backgrounds who do not use drugs. These risks are seen in all combinations of drug use.
The authors accept that the study design can not remove all potential biases. For example, body mass index was not recorded during this period; this could affect birth weight and hypertensive disorders. Information on alcohol use was not collected nor was previous obstetric history. Data on viral infections and sexually transmitted infections were not collected though we know that our population of drug-using women have low rates of HIV and Hepatitis B infection but high rates of hepatitis C infections.
An unexpected finding was an almost complete lack of hypertensive diseases in pregnancy in the drug-using population, adjusting for parity and smoking. The authors were not aware of this as a feature described in the literature and could not offer any scientific explanation for why women using a range of drugs appear "protected" against these complications whilst an increased risk of other placental pathology. 
Despite multidisciplinary co-ordinated antenatal care, women with substance abuse during pregnancy are at significant risk of adverse obstetric and perinatal outcome.
To conclude, comparing effects on pregnancy outcomes of drug-abusing pregnant women we can notice that the greatest difference was in preterm-births (25%) experienced by drug abusers compared to 8% in control women. Also, the incidence of low birth weight was significantly higher amongst drug-using women compared to control group. The growth restriction was as well higher in drugs abusers, the same we can say about risk of abruption. On the other hand the risk of pre-eclampsia and hypertensive events were significantly reduced in drug-addicted women.
Article No.3: Treatment of opioid dependent pregnant women: clinical and research issues
Opioid-dependent pregnant women face tremendous stigma from their family, social networks, and society. Health care providers can mitigate this source of stress by directly addressing their patient's fears, guilt and treatment resistance. Based on some concerns ( e.g. neonatal withdrawal), some pregnant opioid-dependent women are treated inadequately, with either no medication or sub-therapeutic levels of medication in order to reduce the exposure and risk for physical dependence in the fetus. However, the benefits of methadone are well documented.
In pregnant patients, methadone substantially minimizes the peak and trough in maternal serum opioid levels that typically occur with repeated use of short-acting opioids (i.e., heroin), thereby reducing the harm the fetus encounters as a result of repeated intoxication and withdrawal. Compared to other approaches to treatment of opioid dependence available at the time, methadone maintenance was the most cost-effective, producing the greatest reductions in heroin use, criminal activity, and days of hospitalizations. Thus, the benefits of methadone are clear. Methadone maintenance relative to medication-assisted withdrawal provides superior relapse prevention, reduces fetal exposure to illicit drug use and other maternal risk behaviors, improves adherence with obstetrical care, and enhances neonatal outcomes (e.g., heavier birth weight).
Following the approval of buprenorphine in non-pregnant populations as a treatment for opioid dependence, women have conceived while on this medication - and other women have entered treatment requesting buprenorphine due to its unique pharmacology and its availability in the private practitioner setting. Thus, there is new interest in better understanding the use of opioid maintenance medications during pregnancy and evaluating the suitability of buprenorphine to be approved by the FDA for use during pregnancy.
Materials and methods
Evidence-based guidance is needed to optimize the care of the thousands of pregnant women each year who are prescribed either methadone or buprenorphine. The study was made to focus on appropriate use of methadone and buprenorphine in management of opioid-dependent pregnant women based on both on the collective published literature and the clinical and research experiences of the authors. The Maternal Opioid Treatment: Human Experimental Research (MOTHER) project was started in 2005 to examine the comparative safety and efficacy of methadone and buprenorphine in the treatment of opioid-dependence among pregnant women and their neonates. MOTHER is double-blind, double-dummy, flexible-dosing, parallel-group clinical trial that involves eight clinical sites. It is the first large-scale study to formally examine the relative merits of each of the currently available opioid agonist agents in pregnant opioid dependent women.
Guidelines for comprehensive assessment of pregnant and non-pregnant opioid-dependent patients are available. These assessments focus on obstetric/gynecological status, nutrition, social functioning, medical and psychiatric history. A comprehensive evaluation may start with the Addiction Severity Index, an assessment instrument that examines seven domains of functioning affected by substance addiction, namely medical, legal, employment, alcohol, drugs, psychological and family/ social. Thus, the ASI is an assessment tool that can inform treatment planning. Ideally, clinicians should use a version of the ASI tailored to women and pregnancy. In addition to assisting with initial treatment planning, results of regular ASI assessments can aid in assessing treatment progress and addressing relapse, if it occurs. The ASI has predictive validity in pregnant patients, with greater medical and drug ASI problem severity being associated with longer treatment retention in intensive comprehensive care.
Since methadone is the only medication recommended for pregnant opioid-dependent patients, buprenorphine should be prescribed only when the benefits outweight the risks and the patient has refused methadone. As was noticed in this study, many patients were likely to be transferred from buprenorphine to methadone.
During the drug stabilization period in this randomized double-blind study, dose increased during the course of pregnancy for both methadone and buprenorphine which made on average 3 unit increase (totaling averages of 30 mg for methadone and 6 mg for buprenorphine).
In opioid-dependent pregnant patients in the second trimester, transition from slow-release methadone resulted in a "transient dysphonic status" that was observed for two days, opposite to non drug-addicted patients.
Both methadone and buprenorphine are indicated treating drug-addicted expectant mothers, and both of them are considered safe for use. Methadone is preferred one because the buprenorphine has more complex pharmacology and complexity of possibly precipitating withdrawal. The major complain in buprenorphine use was dysphonic mood and "clear headed status".
Dosing of buprenorphine and methadone especially during induction and stabilization periods should be highly taken in consideration and done with great care according the severity of drug-dependency of the expectant mother. 
To conclude all three articles I should say that that substance abuse during the pregnancy is highly associated with significant maternal and fetal morbidity. The complication for care is that the mother is the cause of the problem that potentially harms not only herself but also her unborn child. It is the role the health care professional to provide non-judgmental, supportive environment to minimize the risk, not only during pregnancy and the neonatal period but also in long-therm.
In all three articles that I reviewed the substituting drug substances with methadone or buprenorphine was recommended as a way to minimize the teratogenic effects on both baby and the mother.
Most common using drug substances during pregnancy outcomes are considered pre-term births, low birth weight, stillbirth, miscarriages and abdominal abruption.
As illicit substance misuse is increasing in all layers of society, maternity services, physicians and other health care professionals should adopt to those trends and provide care which directed to this specific problem.