The quality of evidence (I-III) and classification of recommendations (A-L) are defined at the end of the "Major Recommendations."
Identification of Substance-related Disorders in Pregnancy
Screening and Assessment/Role of Toxicology Testing
- All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A)
- When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B)
- Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A)
Components of Office Management
- Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B)
- Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B)
Smoking Cessation Counselling/Pharmacotherapy
- Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A)
Opioid Dependence/Opioids for Chronic Non-Cancer Pain
- Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B)
- Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B)
- Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B)
Peripartum Pain Management
- Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B)
- The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B)
Quality of Evidence Assessment*
I: Evidence obtained from at least one properly randomized controlled trial.
II-1: Evidence from well-designed controlled trials without randomization.
II-2: Evidence from well-designed cohort (prospective or retrospective) or case–control studies, preferably from more than one centre or research group.
II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.
Classification of Recommendations†
A. There is good evidence to recommend the clinical preventive action.
B. There is fair evidence to recommend the clinical preventive action.
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.
D. There is fair evidence to recommend against the clinical preventive action.
E. There is good evidence to recommend against the clinical preventive action.
L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.
†Adapted from the Classification of Recommendations criteria described in The Canadian Task Force on Preventive Health Care.