[CG] Alcohol and other drugs in pregnancy: guideline for management flowchart

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First visit by pregnant woman using alcohol and / or drugs.

Use of alcohol – Confirm and quantify from history.

Use of drugs.

  1. Confirm pregnant. (Confirm by scan before SNIPS prescribing).
  2. Take drug history and screen fresh supervised urine by dipstick.
  3. Send same sample to lab for formal confirmatory toxicology screen.

All pregnant women using drugs (including prescribed opiates and prescribed benzodiazepines

≥ diazepam 20mg/day or equivalent) and / or alcohol above recommended limits should be discussed with SNIPS, the Special Needs in Pregnancy Service (formerly WRHS), ideally with transfer of care.

a) Opiate use (confirmed by dipstick)

b) Benzodiazepine use (confirmed by dipstick)

c) Opiate and benzodiazepine use (confirmed by dipstick)

d) Inpatient management of women already on substitute prescribing for opiate use (confirmed by dipstick)

Additional Obstetric Care

  1. Record use of drugs (illicit and / or prescribed) on yellow alert sheet (maternal and neonatal sections) in maternal case notes.
  2. Suboxone (buprenorphine + naloxone) is contraindicated in pregnancy (see guideline)
  3. Opiates and / or benzodiazepines can cause reduced variability on CTG. Other explanations must be considered and excluded before assuming a causal link in this group of patients. Particular attention should be given to any CTG with more than one abnormal parameter.

Important notes

  1. Use of illicit opiates constitutes an obstetric emergency. Women reporting such use should be admitted immediately for stabilisation on prescribed methadone. Prescription of substitute methadone can be initiated by mainstream staff in accordance with the SNIPS guideline. 
  2. Transfer to SNIPS of existing maintenance methadone prescription must be authorized by a member of SNIPS staff. This must be arranged during normal working hours and with a minimum of one week’s notice.
  3. Use of benzodiazepines is a significant obstetric problem but does not invariably warrant emergency admission. Inpatient detoxification (see above) is advisable but management cannot be agreed if the woman is intoxicated in which case she should be invited to return the following day for review.
  4. SNIPS staff should be notified as soon as possible with regard to ongoing management.  

e) Use of Alcohol (confirmed by history)*

Additional Obstetric Care

  1. All women using alcohol above recommended limits should be offered a fetal anomaly scan (FAS) at 20 weeks gestation according to protocol.
  2. In addition, women using alcohol above recommended limits should be offered serial growth scans in 3rd
  3. Record use of alcohol and other drugs (illicit and / or prescribed) on yellow alert sheet (maternal and neonatal sections) in maternal case notes.

* Taking of detailed history of alcohol consumption and identification of consumption above recommended level is part of the routine antenatal booking history.  Women identified as drinking above recommended levels should additionally receive “information and brief advice” (IBA) using the agreed tool.

Last reviewed: 01 April 2016

Next review: 09 May 2021

Author(s): Dr E Ellis, associate specialist obstetrician, PRM on behalf of Obstetric Guidelines Group, GGC; Mrs J Grant, Lead Clinical Pharmacist W&C O&G GGC

Version: 1

Approved By: Dr C Bain, Clinical Director, Obstetrics