I read with interest the recent editorial by Johnson et al (Reference Johnson, Gerada and Greenough2003) and I agree with the authors that substance misuse, including in women of reproductive age, has increased markedly over the past 20 years. In my practice of obstetrics and obstetric anaesthesia, I have provided care to many drug-misusing parturients and would like to add some comments on this timely topic.

Five million Americans are regular users of cocaine, 6000 use the drug for the first time each day and more than 30 million have tried cocaine at least once. Approximately 250 000 women in the USA meet the criteria for intravenous drug abuse. Nearly 90% of these women are of childbearing age (Reference KuczkowskiKuczkowski, 2003). Psychological personality characteristics seem to predispose to, rather than result from, drug addiction. Most often, drug misuse is first suspected or diagnosed during medical management of another condition such as hepatitis, HIV/AIDS or pregnancy. Most parturients with a history of drug misuse deny it when interviewed preoperatively by primary care physicians, obstetricians or obstetric anaesthesiologists. A high index of suspicion for drug misuse in pregnancy, combined with non-judgmental questioning of every parturient, is therefore necessary (Reference KuczkowskiKuczkowski, 2003). Risk factors suggesting substance misuse in pregnancy include lack of prenatal care, history of premature labour and cigarette smoking. Substances most commonly misused in pregnancy include cocaine, amphetamines, opioids, ethanol, tobacco, marijuana, caffeine and toluene-based solvents. Polysubstance misuse is very common. The diverse clinical manifestations of substance misuse, combined with the physiological changes of pregnancy and the pathophysiology of coexisting pregnancy-related disease, might lead to life-threatening complications and significantly affect the pregnancy outcome.