Talk to your health care provider about medications you are taking, are about to take, or considering stopping during your pregnancy or while breastfeeding.
Medications may reach your baby through the placenta or through your breastmilk. The potential harmful effects of medication on pregnant women or babies are not always known or studied.
It is important to discuss any medicines you are taking with your health care provider while you are planning your pregnancy or as soon as possible. Methadone treatment while pregnant or breastfeeding is safe for your baby.
Ask your health care provider the following questions about medication use during pregnancy.
- Is this medication safe to take during pregnancy?
- What are the benefits?
- What are the risks?
- Are there any alternatives?
If you need to take medication while breastfeeding, ask your health care provider if it is okay to breastfeed while taking this medication or if there are safer alternatives. Most medications are safe to take while breastfeeding.
Taking recreational or street drugs during your pregnancy or while breastfeeding is harmful to you and your baby.
Discuss any recreational or street drug useÂ with your health care provider before you are pregnant or as soon as possible. It is safest not to use drugs during pregnancy or while breastfeeding. If you are considering quitting drug use while pregnant speak to your health care provider about the safest way to quit.
Babies born to mothers who take drugs may:
- Be born too soon and be smaller than average.
- Have health problems.
- Go through drug withdrawal if their mother uses drugs prior to birth.
- Have problems learning.
Ask for help if you want to quit using recreational or street drugs.
It is never too late to reduce or stop using drugs. It can be very difficult to admit to drug use. Finding support from someone you can trust is key to getting help. Your partner, family members, or friends may be a great source of support. Speak with your health care provider about services to help you quit safely. Some people use drugs because of events in their lives such as abuse or trauma. Counselling or other services may help.
For help to stop using drugs:
- Call the Drug and Alcohol Helpline at 1-800-565-8603 for free, confidential information about alcohol and drug addiction services in Ontario.
- Call the Centre for Addiction and Mental health (CAMH) at 1-800-463-6273 for a self-referral for assessment and treatment around addiction/substance use.
Learn more about medications and drugs.
You can find out more about medication and drug use during pregnancy and breastfeeding from the following resources. More suggestions can be found in the Resources and Links section.
- Your health care provider
- MotheriskÂ Helpline
416-813-6780 (Toronto and GTA)
- Motherisk Alcohol and Substance Use Helpline
- Telehealth Ontario 1-866-797-0000
- Your local pharmacist
About Medications and Drugs during Pregnancy
The supporting evidence that follows will address medications including, prescription, over-the-counter, and herbal products as well as recreational or street drugs.
Prescription medications are drugs that can only be legally obtained with a medical prescription from a qualified health care provider. Products needing a prescription are regulated as drugs under the federal Food and Drug Regulations.1 In contrast, over-the-counter medications can be obtained without a prescription. According to the World Health Organization (WHO), herbal medicines include herbs, herbal materials, herbal preparations, and finished herbal products that contain active ingredients from plants.2 Not all herbal products sold are regulated, and quality and ingredients cannot always be assured.
Recreational or street drugs are substances taken for nonmedical purposes (usually for mind-altering effects). Such drugs include various amphetamines, anesthetics, barbiturates, opioids, and psychoactive drugs.3
The following drugs are discussed in greater detail because of their prevalence in the population and because of the specific consequences during the perinatal period.3
- Amphetamines and methamphetamine.
- Opioids such as heroin and methadone.
It is difficult to know how many pregnant women and breastfeeding mothers are on prescription medication and/or take over-the-counter medications. The National Longitudinal Survey of Children and Youth (NLSCY) reported that â€śbetween 1984 and 2003, up to 33 percent of Canadian women took medications during their pregnancies.â€ť 4 According to Statistics Canada, women reported higher rates than men of prescription drug use.5 The reported rate of prescription drug use during pregnancy may be low due to individuals borrowing or sharing medications.
An Ipsos Reid survey done in 2010 shows that 73 percent of Canadians regularly take natural health products (NHPs) like vitamins and minerals, herbal products, and homeopathic medicines.1 There is no prevalence data on the use of herbal remedies during pregnancy.
Since recreational or street drug use is illegal, it is difficult to get accurate information about the prevalence of maternal drug use during pregnancy. Pregnant women may under-report drug use.6
According to the 2006 â€“ 2007 Canadian Maternity Experiences Survey (MES), 7 percent of women reported using at least one recreational or street drug in the three months prior to pregnancy and 1 percent reported using street drugs during pregnancy.7 Women between the ages of 15 and 24 were most likely to report drug use during pregnancy, and 10.5 percent of women in Ontario reported drug use prior to pregnancy.7 Finally, according to the available information, the recreational or street drug most frequently used by pregnant women and women of childbearing age was cannabis followed by cocaine and opiates.8, 9
Who is at Risk?
Women with chronic health conditions
The 2011 â€“ 2012 Better Outcomes Registry & Network (BORN) report indicated that 28 percent of Ontario women giving birth in Ontario had health conditions that may or may not have required prescription medication. 10 With approximately 50 percent of pregnancies being unplanned, many women may take prescription and over-the-counter medications without knowing that they are pregnant. 7, 11 Women with chronic health conditions including, arthritis, asthma, hypertension, diabetes, depression, heart disease, or epilepsy that become pregnant are likely to be on medications. Pregnant women over the age of 35 are more likely to have pre-existing medical conditions, such as hypertension, arthritis, diabetes, and breast cancer. 12 As a result of pre-existing medical conditions, women of advanced maternal age are more likely to be taking medications. 13 Common examples are blood pressure medications and medications to control the symptoms of arthritis. Women with chronic health conditions may also be using over-the-counter medications or herbal remedies for managing chronic medical conditions.
Women with pregnancy-related conditions
Women with chronic health conditions may find that the symptoms of their illness change with pregnancy. With the physical and psychosocial changes that happen with pregnancy, many symptoms get worse. Pregnancy may also create new issues for all women such as nausea, vomiting, and sleep issues. 14 These conditions may increase a womanâ€™s likelihood of accessing prescription, over-the-counter, and herbal products.
Adolescent women are less likely to plan their pregnancy and may take longer to confirm or acknowledge their pregnancy and seek out medical care. These factors put them at higher risk of taking prescription and over-the-counter medication without consulting a health care provider to review risks, benefits, and alternatives. 15
Some women are more likely to use recreational or street drugs during pregnancy than others.
The following factors have been found to be associated with drug use during pregnancy.16, 17
- Low education level or family income level.
- Historical trauma.
- History of domestic violence.
- Personal history or presence of mental health concerns (e.g., depression, anxiety disorders, and personality disorders).
- Family history of substance use disorders.
- Partner who drinks or uses drugs.
- Personal history of drug use disorders.
- Alcohol and tobacco use during pregnancy.
Physicians frequently rely on the Federal Food and Drug (FDA) pregnancy risk category system and the Compendium of Pharmaceuticals and Specialties (CPS) to evaluate the safety of medications during pregnancy. However, both the FDA classification system and the product monographs of the CPS are inadequate to address the complexity of weighing the benefits of treatment against the possible risk of drug exposure. 18
The FDA announced in May 2008 that they will replace the A, B, C, D, and X pregnancy risk classification system with a narrative framework consisting of several sections. 18 The new labeling information for medication during pregnancy will contain a risk summary section that incorporates human and animal data and a clinical consideration section that addresses risk assessment and how to handle inadvertent fetal drug exposure. 18 This system is similar to what Motherisk uses when providing information to health care providers and clients.
LactMed Â®, a database managed by the Toxicology and Environmental Health Information Program (TEHIP) in the Specialized Information Services (SIS) division of the National Library of Medicine (NLM) within the National Institute of Health (NIH), contains information on drugs, herbal products, and other chemicals to which breastfeeding mothers may be exposed. It includes relevant scientific literature on the levels of these substances in breastmilk and infant blood if available and the possible adverse effects on the nursing infant. Suggested therapeutic alternatives are also provided where appropriate. A peer review panel reviews the data to assure scientific validity. LactMed Â® has been suggested as the most reliable resource for safety recommendations in lactation. 19
An additional resource that may be used is Medications and Motherâ€™s Milk. In this resource, Dr. Thomas Hale has created lactation risk categories for medications taken while breastfeeding that rates drugs from safest (L1) to contraindicated (L5). 20
Medication should be prescribed during pregnancy when the expected benefits to the mother outweigh any potential risks. 21 The decision to take a prescription medication during pregnancy should be an informed decision made by a woman in consultation with her health care provider. In some cases, alternative treatments such dietary and lifestyle changes may be adequate in managing some chronic health care issues during pregnancy and/or may result in requiring a lower dose of medication to achieve stabilization. Prescription medication during pregnancy should be taken at the lowest therapeutic dose for the shortest period needed. 21
Many physiological changes that occur during pregnancy may modify the pharmacokinetics of drugs, and a womanâ€™s dosage may need to be modified to ensure therapeutic levels. 22, 23 It is important for pregnant women to maintain the appropriate dose of the required medication to maintain control of chronic illnesses such as depression, diabetes, and hypertension as all have potentially adverse effects on both the mother and the baby. 22, 23
Pregnant women who need to be on prescription medication may worry and have feelings of guilt. However, research has shown that most women and health care providers overestimate the teratogenic risk associated with drug use during pregnancy. 22
Every pregnancy has the risk for major malformations regardless of fetal drug exposure. 24 When considering the risks of all teratogens, including drug exposure, four areas of fetal development are considered: growth alteration; functional deficit; structural malformation; and death. 23,24 The effects of a medication on the unborn baby depend on the amount of the drug taken; the frequency of use; the stage of fetal development; and genetic susceptibility. 23, 24, 25 Adequate nutrition may also play a role; for example, adequate folic acid intake may decrease the risk of certain malformations in women with epilepsy. 26, 27
The most significant adverse effects of medications often occur early in pregnancy before many women realize that they are pregnant. 23 The babyâ€™s organs are forming during weekâ€™s three to eight and during this time the fetus is at risk of developing major anomalies. Toward the end of pregnancy, exposures may increase the risk for more subtle abnormalities as well as fetal withdrawal symptoms for some drugs. 24
See Appendix A for a listing of common maternal medical conditions, effects on pregnancy/infant, and safety considerations for prescription medication in pregnancy.
The benefits of breastfeeding to both child and mother are very clear. Some mothers will require medication of some type during the time they are breastfeeding. While it is true that most medications enter breastmilk to some degree, with a few exceptions, the concentrations of most medications in breastmilk are very low, and the dose the baby receives is often sub-clinical. 28 Package inserts and information provided in the CPS most often indicate contraindications to breastfeeding. This information is mainly due to concern about liability and does not accurately represent the amount of medication present in breastmilk. 28 LactMedÂ® and Haleâ€™s lactation risk categories can be used as reliable resources when counselling breastfeeding women about prescription medication and breastfeeding.
Domperidone has been prescribed (by some physicians) to increase milk supply; this is an off-label application of the drug. This medication has not received approval from Health Canada to be used to support lactation. 29 In March 2012, Health Canada released an advisory to health care professionals and the public warning of possible, serious side effects associated with the use of domperidone. 29 The warning was based on two studies reporting an association of domperidone with serious abnormal heart rhythms and sudden cardiac death (SCD). 30,31 According to Motherisk, the results of the studies are not directly applicable to breastfeeding and should not change the way a health care provider would normally manage otherwise healthy, breastfeeding women. 29 Domperidone should be used at the lowest effective dose for the shortest time possible. 29
It is not recommended to use narcotic analgesics (e.g., codeine) for more than four days especially when breastfeeding a newborn infant. Newborn infants appear to be particularly sensitive to the effects of even small dosages of narcotic analgesics. Maternal use of oral narcotics during breastfeeding can cause drowsiness, central nervous system depression, and even death in the breastfed infant with a possible role for pharmacogenetics. 32
The purpose of over-the-counter (OTC) medications during pregnancy is to help women with symptoms they might experience during their pregnancy.
There is a general misconception that since OTC drugs are readily available and viewed as safe for adults they are acceptable during pregnancy. OTC medications should be treated the same as prescription medication. Therefore, if a woman is considering taking an OTC medication, the safety of taking the medication should be discussed first with her health care provider and/or pharmacist. 33, 34
The following table provides an overview of physical complaints; over-the-counter medications; safety for mother and baby; and complimentary approaches for expectant mothers and their babies.
Nicotine replacement therapy (NRT)
NRT options are available over-the-counter as a smoking cessation aids and come in various forms, including gum, patches, and lozenges. The most recent data suggests that using NRT is no more harmful and is probably safer than continuing to smoke during pregnancy. 60 Discussion with health care provider is recommended.
For more information about NRT, see the Smoking file.
Mosquito bites and ticks may have negative consequences during pregnancy by transmitting diseases such as West Nile virus. 61 When used according to manufacturer’s instructions, DEET is an effective way to prevent mosquito bites and ticks. 62 Although this product is recognized as low toxicity, the current research is limited in its use during pregnancy. It is suggested that pregnant women avoid, if possible, situations where they may be exposed to mosquitoes or ticks. 63
For more information about DEET, see the Safety during Pregnancy file.
Sunscreen absorption is subclinical and, therefore, safe to use during pregnancy. 64
For more information about sunscreen, see the Safety during Pregnancy file.
Most OTC medications pose no risk to the baby. There are some medications that should be limited or avoided while breastfeeding.
The following are some basic guidelines for taking OTC medicines for breastfeeding women:
- Take oral medicines after breastfeeding or before the baby’s longest sleep period. This may give the medicine a chance to leave the system before breastfeeding the baby again.
- Acetaminophen and NSAIDs usually provide safe pain relief for women who are breastfeeding. 20
- Avoid using aspirin because it can cause rashes and bleeding problems in nursing babies. Aspirin-containing medications also create an increased risk of Reye syndrome. Aspirin should not be the first choice for pain relief for breastfeeding mothers. 20
- Limit long-term use of sedating antihistamines. Antihistamines will pass into breastmilk but not likely at high enough levels to cause clinical effects. Sedating antihistamines cause side effects in nursing babies such as drowsiness. Breastfeeding women should ask their health care provider or pharmacist before taking OTC medication. 52
- Pseudoephedrine is used as a nasal decongestant. Although it is excreted into breastmilk in low levels, caution should be used with this product as it may reduce milk production in late-stage lactation (i.e., mothers who are breastfeeding infants older than eight months of age). 65
There are many factors to consider before using herbal products during pregnancy. The safety and effectiveness of most herbal products during pregnancy has not been established. 66,67 Natural health products (NHPs) sold in Canada are subject to the Natural Health Products Regulations, which came into force on January 1, 2004. To be legally sold in Canada, natural health products must have a product licence. The Canadian sites that manufacture, package, label, and import these products must have site licences. 68 A licensed product has an eight-digit NPN or DIN-HM number. Not all products sold in Canada have gone through evaluation yet these products receive an exemption number and can also be legally sold in Canada.
The concentration of active ingredients in herbal products can vary considerably from product to product. 69 The active ingredients may cross the placenta into the baby, and the effects on the baby are largely unknown. It is recommended that before taking any herbal products a woman consult her health care provider to discuss risks and benefits. 20,69
See the table 2 for more information about commonly used herbal products.
Breastfeeding women should be very careful about herbal products, especially when the baby is a newborn or premature. 69 Like conventional medicines, certain herbal products may transfer into the breastmilk. 69 Some herbal and traditional medicines may be harmful to the baby while others can affect the breastmilk production. 20, 69 Most herbal products do not have enough documented information to determine their safety in breastfeeding and the concentration of active ingredients may vary.
See the table 3 for more information about herbal products and their effect on breastfeeding.
Recreational or Street Drugs
Recreational or street drugs act as disruptors, stimulants or depressors on an individual’s central nervous system. The following table shows a comparison of the categories of recreational or street drugs based on their effects on the central nervous system.
Prescription drug misuse is on the rise.83 Prescription drug misuse most commonly refers to the misuse of opioids (i.e., natural and synthetic derivatives of opium). Canada had the highest per capita consumption of oxycodone (a prescription opioid) in the world.82 Opioids (e.g., morphine and codeine) are medications that are used to treat acute and chronic pain. The risks of prescription drug misuse to maternal and fetal health are dependent on the type of prescription medication and timing of exposure during pregnancy.83
Drug use may be associated with different social and health problems for pregnant women such as:
- Sleep disorders.
- Physical health problems (e.g., cardiovascular problems, high blood pressure). 84
- Infections (e.g., HIV/AIDS, hepatitis).
- Inadequate medical or prenatal care. 85
- Mental health issues.
- Psychosocial problems (e.g., financial problems, domestic violence, relationship breakdown). 84,85
Drug use may adversely affect parenting skills (e.g., physical or emotional unavailability, inconsistent care) and the development of the child’s attachment. 86,87 An infant who was exposed to drugs during the end of pregnancy may have withdrawal symptoms (e.g., irritability, crying, insomnia) in the first days to weeks and be more difficult to console. This, in turn, may increase the mother’s stress level and reduce her desire to interact with her baby. 24 Some pregnant women who use drugs do not have access to suitable role models who can guide them in their role as mothers. These women may require more support and guidance in their parental role and in developing an emotional bond with their child. Alternatively, for some women a pregnancy may be a turning point in their life and provide an impetus to make positive life changes.
Women who use drugs have higher-risk pregnancies owing to potential adverse effects on the unborn child. 88
Drugs (especially those with a high potential for dependence, such as cocaine or opiates) may cross the placental barrier and affect certain aspects of fetal development. 8, 24 The effects of drugs on the fetus and long-term child development are contradictory and have many confounders. 85
Methadone maintenance treatment is considered the standard of care for women who are pregnant and dependent on opioids. The potential benefits include:
- Safer, medically supervised opioid use (stable supply, pure quality, no fluctuating blood level, no exposure to contaminants).
- Better antenatal care.
- Increased fetal growth.
- Reduced fetal mortality.
- Increased likelihood of carrying pregnancy to term.
- Fewer birth complications.
- Decreased risk of transmission of HIV (and potentially HCV and other blood-borne pathogens) (including decreased risk of transmission of HIV to infants).
- Decreased cases of preeclampsia and neonatal abstinence syndrome.
- Increased likelihood that infant will be discharged into his or her parents’ care.
- Increased retention in treatment.122, 123
The most frequently reported effects of drug use during pregnancy on the unborn baby are set out in the following table.
Based on current scientific data it is not possible to determine whether the effects of maternal drug use on an unborn baby are caused directly by the substance itself or by exposure to other health-harming factors. 86,95
Few studies have measured the influence of confounding factors often associated with drug use, such as:
- Patterns of use (e.g., product quality; dose taken; administration route used [oral, nasal, injection]; frequency of use; stage of fetal development at the time of use). 95
- Polydrug use. In most cases of drug use, drugs are used in combination. For example, it has been documented that 93 percent of pregnant women who used cocaine or heroin also used other substances (primarily alcohol and tobacco) with harmful effects on the health of their baby. 96
- Maternal traits (e.g., overall health; genetic and physiological factors that lead to individual differences in metabolism; and physical and psychological tolerance for drugs). 97,90
- Socioeconomic factors and living conditions (e.g., malnutrition, lack of prenatal care, lack of financial resources, underprivileged neighbourhood, criminality, prostitution). 85,90
Whether a drug’s effects on an unborn baby are caused directly by the substance and/or by the influence of the above confounding factors, it is strongly recommended that women not use drugs while pregnant because of the risk to the unborn child. Some drugs such as opioids may require a gradual weaning as sudden stopping can trigger uterine contractions at all stages of gestation. 98
If a woman used drugs before she knew she was pregnant and is concerned about having harmed her baby’s development, reassure her by reminding her that drug use during pregnancy comes with potential, not automatic, risks to the pregnancy and unborn child. Furthermore, the quality of the environment in which the child grows up is important. Other factors in the child’s environment may offset certain effects of the drugs, such as the mother’s healthy lifestyle; a stimulating, warm family environment; or a quality mother-child relationship.
Still, drug use is never risk-free. Therefore, it is highly recommended that women seek professional advice to safely quit using drugs. To stop using opioids, alcohol, and benzodiazepine medical detoxification will be required.
For further information regarding treatment options for recreational or street drug addiction, please see Appendix B.
Drugs may appear in breastmilk and interfere with production, quantity, and/or composition. Infant exposure to drugs through breastmilk has been associated with adverse health effects as shown in the following table.
Because of the potential for harm, it is advised that a breastfeeding mother not consume any recreational or street drugs.
The exposure of infants to methadone through their mothersâ€™ breast milk is minimal. Women using methadone for treatment of opioid dependence should not be discouraged from breastfeeding. The benefits of breastfeeding largely outweigh any theoretical minimal risks.124
For further information regarding treatment options for recreational or street drug addiction, please see Appendix B.
Women would benefit from a referral to the appropriate health care provider if they:
- Have an existing medical condition.
- Are taking prescription medication.
- Are taking over-the-counter medication or herbal products and have not consulted with their health care provider.
- Disclose recreational or street drug use.
Women who need more information about the use of prescription, over-the-counter, and herbal medications during pregnancy and while breastfeeding may be referred to:
- Their local pharmacist.
- Motherisk 1-877-439-2744.
- Telehealth Ontario at 1-866-797-0000.
Women who need more information about the use and treatment of alcohol, tobacco, recreational or street drugs during pregnancy and while breastfeeding may be referred to:
- Motherisk Alcohol and Substance Use Helpline 1-877-327-4636.
- Centre for Addiction and Mental Health (CAMH) 1-800-463-6273.
- Drug and Alcohol Helpline 1-800-565-8603.
- Mental Health Helpline 1-866-531-2600.
- Distress and Crisis Ontario (DCO).
Note, substance use by a caregiver is reportable. In cases where a woman continues to use recreational or street drugs while pregnant and/or parenting, Childrenâ€™s Aid Society should be notified. The Ontario Association of Childrenâ€™s Aid Societies provides protective services to infants and children through one of its 46 Societies.
Resources & Links
- Society of Obstetricians and Gynaecologists of Canada (SOGC)
- Clinical Practice Guideline: Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy: Executive Summary (2014)
- Clinical Practice Guideline: Intimate Partner Violence Consensus Statement (2005)
- Clinical Practice Guideline: Principles of Human Teratology: Drug, Chemical, and Infectious Exposure (2007)
- Clinical Practice Guideline: Screening for Gestational Diabetes Mellitus (2002)
- Clinical Practice Guideline: Substance Use in Pregnancy (2011)
- World Health Organization (WHO)
- EatRight Ontario
- HER Foundation (Hyperemesis Education & Research)
- Organization of Teratology Information Specialists (OTIS)
- Pregnancy-Related Issues in the Management of Addictions (PRIMA)
- Motherisk Helpline
416-813-6780 (Toronto and GTA)
- Motherisk Alcohol and Substance Use Helpline
- Drug & Alcohol Helpline 1-800-565-8603
- Telehealth Ontario 1-866-797-0000
Prenatal Education Provider Tools
- Centre for Addiction and Mental Health (CAMH)
- Centers for Disease Control and Prevention (CDC)
- Organization of Teratology Information Specialists (OTIS)
- Josephâ€™s Health Centre, Toronto
- Toronto Centre for Substance Use in Pregnancy (T-CUP) (1-416-530-6860)
Client Resources and Handouts
- Best Start Resource Centre
- Breastfeeding Inc.
- Health Canada
- HER Foundation (Hyperemesis Education & Research)
- Organization of Tetralogy Information Specialists (OTIS)
- Koren, G., (2007). Medication Safety in Pregnancy and Breastfeeding: The Evidence-Based A to Z Clinicianâ€™s Pocket Guide. Toronto, Ontario. McGraw-Hill Medical.
- Hale, T., (2014). Medications & Mothersâ€™ Milk. Amarillo, Texas. Hale Publishing.
- Koren, G. (2004). The Complete Guide to Everyday Risks in Pregnancy and Breastfeeding: Answers to All Your Questions about Medications, Morning Sickness, Herbs, Diseases, Chemical Exposures and More. Toronto, ON: Robert Rose Publishers
- Millis, J.J., Dugoua, D., Perri, D., & Koren, G. (2006). Herbal Medicines in Pregnancy and Lactation: An Evidence-Based Approach. Taylor & Francis, Toronto, Canada.
- Ordean, A., Midmer, D., Payne, S., Hunt, G., (2008). Pregnancy-Related Issues in the Management of Addictions: A Reference for Care Providers. Toronto, Canada. Department of Family and Community Medicine, University Of Toronto.
Appendix B: Treatment Options for Recreational or Street Drug Use
The vast majority of women who use recreational or street drugs quit using drugs or cut back when they find out they are pregnant. Although it is strongly recommended that women quit using drugs completely during pregnancy, not every woman will choose or be able to do so.119 Harm reduction may prove to be a more appropriate solution for these women. The aim of this approach is to reduce the harmful consequences of drug use rather than to completely eliminate the drug use itself. As such, it provides a certain number of benefits and a certain level of risk reduction for the expectant mother and her unborn baby.96
Methadone/buprenorphine maintenance treatment
Methadone is a doctor-prescribed medication used to treat opioid addiction.120 It is indicated for pregnant women with an opioid use disorder. Sudden discontinuation of opioids during pregnancy may lead to severe withdrawal which is associated with a risk of uterine contractions increasing the risk of premature delivery or miscarriage. Methadone maintenance treatment is used to stabilize the pregnant woman’s condition and to help her reduce/quit using drugs.121
Taking methadone during pregnancy may be associated with smaller birth parameters and withdrawal symptoms in the newborn. However, the benefits of methadone outweigh risks of continued drug use; it does not produce euphoric effects, but acts to significantly reduce cravings, keeps the mother functional and promotes better prenatal care.84,121
Methadone therapy is currently the gold standard for managing opioid dependence during pregnancy. However, when access to a methadone clinic is not available, or a woman refuses methadone treatment, buprenorphine is an alternative opioid replacement treatment.82
- Health Canada. (2014). Drugs and health products. Retrieved from http://hc-sc.gc.ca/dhp-mps/index-eng.php
- World Health Organization. (2000). General guidelines for methodologies on research and evaluation of traditional medicine. Retrieved from http://whqlibdoc.who.int/hq/2000/WHO_EDM_TRM_2000.1.pdf?ua=1
- Society of Obstetricians and Gynaecologists of Canada. (2011). Substance use in pregnancy. JOCG, 33(4), 367-384.
- Garriguet, D. (2006) Medication use among pregnant women. Health Reports, 17(2), 9-18.
- Statistics Canada. (2002). Canadian community health survey.
- Ordean, A., Midmer, D., Payne, S., Hunt, G. (2008). Pregnancy-related issues in the management of addictions: A Reference for care providers. Toronto, ON:Department of Family and Community Medicine, University of Toronto.
- Society of Obstetricians and Gynaecologists of Canada. (2008). The Canadian maternity experiences survey: An overview of the findings. JOGC,30(3), 217-228. http://www.jogc.com/index_e.aspx
- Djulus, J. (2007). Illicit substances. In E. Ferreira (Ed.), Pregnancy and breastfeeding: Guide therapeutic, (pp. 149-168). Montreal, QC: Editions of the CHU Sainte-Justine.
- Schempf, A. H., & Strobino, D.M. (2008). Illicit drug use and adverse birth outcomes: Is it drugs or context? Journal of Urban Health, 85(6), 858-873. Retrieved from http://journals.lww.com/greenjournal/pages/default.aspx
- Better Outcomes Registry and Network Ontario (BORN). (2013). Perinatal Health Reports 2011 â€“ 2012. Retrieved from https://www.bornontario.ca/en/resources/reports/lhin-regional-reports/
- Best Start Resource Centre. (2009). Preconception health: Awareness and behaviours in Ontario. Toronto, ON: Author.
- Best Start Resource Centre (2007). Pregnancy after 35: Reflecting on the trend. Toronto, ON: Author.
- Cleary-Goldman, J., Malone, F. D., Vidaver, J., Ball, R. H., Nyberg, D. A., Comstock, C. H., â€¦ FASTER Consortium (2005). Impact of maternal age on obstetrical outcome. Obstetrics &Gynecology, 105(5), 983-990.
- The Society of Obstetricians and Gynaecologists of Canada. (2009). Healthy beginnings giving your baby the best start from preconception to birth (4th ed.). Mississauga, ON: John Wiley & Sons Canada.
- Fleming, N., Tu, X., & Black, A. (2012). Improved obstetrical outcomes for adolescents in a community-based outreach program: A matched cohort study. JOGC,34(12), 1134-1140. Retrieved from http://www.jogc.com/index_e.aspx
- Hans, S. L. (1999). Demographic and psychosocial characteristics of substance-abusing pregnant women. Clinics in Perinatology,26(1), 55-74. http://www.perinatology.theclinics.com/
- El Marroun, H., Tiemeir, H., Jaddoe, V. W., Hofman, A., Mackenbach, J. P., Steegers, E. A., â€¦ Huizink, A. C. (2008). Demographic, social and emotional determinants of cannabis use in early pregnancy: The generation R study. Drug and alcohol dependence, 98, 218-226. doi: 10.1016/j.drugalcdep.2008.05.010
- Law, R., Bozzo, P., & Koren, G. (2010). FDA pregnancy risk categories and the CPS: Do they help or are they a hindrance? Canadian Family Physician, 56(3), 239-241. Retrieved from http://www.cfp.ca/
- Akus, M., & Bartick, M. (2007). Lactation safety recommendations and reliability compared in 10 medication resources. Annals of Pharmacotherapy, 41(9), 1352-1360 Retrieved from http://aop.sagepub.com/
- Hale, T. (2014). Medications and mothersâ€™ milk: A manual of lactational pharmacology. Amarillo, TX:. Hale Publishing.
- Medsafe (2013). Medicines and use in pregnancy. Prescriber Update,34(2), 18-19.
- Pace, L. E., Schwarz, E. B. (2012). Balancing act: Safe and evidence-based prescribing for women of reproductive age. Womanâ€™s Health, 8(4), 415-425.
- S. Department of Health and Human Services. (2005). Reviewer guidance: Evaluating the risks of drug exposure in human pregnancies. Retrieved from http://www.fda.gov/downloads/ScienceResearch/SpecialTopics/WomensHealthResearch/UCM133359.pdf
- Chasnoff, I. J. (2008). Drug use in pregnancy: Parameters of risk. The Pediatric Clinics of North America, 35(6), 1403-1412. Retrieved from http://www.sciencedirect.com/science/journal/00313955
- Schardein, J. L. (2004). Chemically induced birth defects (3rd ed.). New York, NY: Marcel Dekker Inc.
- Taggart, K. (2003). Valproic acid less safe than thought; Motherisk to issue new advisory based on results. Retrieved from http://www.motherisk.org/women/commonDetail.jsp?content_id=816
- Morrell, M. J. (2002). Folic acid and epilepsy. Epilepsy Currents, 2(2), 31â€“34. doi:Â 1046/j.1535-7597.2002.00017.x
- Koren, G. (2007). Medication safety in pregnancy and breastfeeding: The evidence-based A to Z clinicianâ€™s pocket guide. Toronto, ON:McGraw-Hill Medical.
- Bozzo, B., & Koren, G. (2012). Heath Canada advisory on domperidone. Retrieved from http://www.motherisk.org/prof/updatesDetail.jsp?content_id=981
- Johannes, C. B., Varas-Lorenzo, C., McQuay, L. J, Midkiff, K. D., & Fife, D. (2010). Risk of serious ventricular arrhythmia and sudden cardiac death in a cohort of users of domperidone: A nested case-control study. Pharmacoepidemiology Drug Safety, 19(9), 881-8. doi: 10.1002/pds.2016.
- Van Noord, C., Dieleman, J. P., van Herpen, G., Verhamme, K., & Sturkenboom, M. C. (2010). Domperidone and ventricular arrhythmia or sudden cardiac death: a population-based case-control study in the Netherlands. Drug Safety,33(11), 1003-14. doi: 10.2165/11536840-000000000-00000
- Parvaz, M., Moretti, M., Djokanovic, N., Bozzo, P., Nulman, I., Ito, S., & Koren, G. (2009). Guidelines for maternal codeine use during breastfeeding. Retrieved from http://www.motherisk.org/prof/updatesDetail.jsp?content_id=918
- Wilson J. G., & Clarke Fraser, F. (1977). Handbook of teratology. New York, NY: Plenum.
- Kacew, S. (1999). Effect of over-the-counter drugs on the unborn child: What is known and how should this influence prescribing? Paediatric Drugs, 1(2), 75-80. Retrieved from http://link.springer.com/journal/40272
- Organization of teratology information specialists (OTIS). (2010) Acetaminophen and pregnancy. Retrieved from http://www.mothertobaby.org/files/acetaminophen.pdf
- Feldkamp, M. L., Meyer, R. E., Krikov, S., & Botto, L. D. (2010). Acetaminophen use in pregnancy and risk of birth defects: Findings from the National Birth Defects Prevention Study. Obstetrics & Gynecology,115(1), 109-115. doi: 10.1097/AOG.0b013e3181c52616
- Briggs, G. G., Freeman, R. K., & Yaffe, S. J. (2015). Drugs in pregnancy and lactation: A reference guide to fetal and neonatal risk. (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
- Kozer, E., Nikfar, S., Costei, A., Boskovic, R., Nulman, I., & Koren, G. (2002). Aspirin consumption during the first trimester of pregnancy and congenital anomalies: A meta-analysis. American Journal of Obstetrics & Gynaecology. 187(6), 1623-30. http://dx.doi.org/10.1067/mob.2002.127376
- Babb, M., Koren, G., & Einarson, A. (2009). Treating pain during pregnancy. Canadian Family Physician, 55(12), 25, 27. Retrieved from http://www.cfp.ca/
- Organization of teratology information specialists (OTIS). (2010). Pregnancy and ibuprofen. Retrieved from http://www.mothertobaby.org/files/Ibuprofen.pdf
- Koren, G., Florescu, A., Costei, A. M., Boskovic, R., & Moretti, M. E. (2006). Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. American Pharmacotherapy. 40(5), 824-9.
- Florescu, A., & Koren, G. (2005). Nonsteroidal anti-inflammatory drugs for rheumatoid arthritis during pregnancy. Retrieved from http://www.motherisk.org/prof/updatesDetail.jsp?content_id=729
- Erebara, A., Bozzo, P., Einarson, A., & Koren, G. (2008). Treating the common cold during pregnancy. Retrieved from http://www.motherisk.org/prof/updatesDetail.jsp?content_id=881
- Facundo, G.-B., Yaron, F., Rezvani, M., & Koren, G. (2006). Exposure to alcohol-containing medications during pregnancy. Retrieved fromhttp://www.motherisk.org/prof/updatesDetail.jsp?content_id=842
- Werler, M. M. (2006).Teratogen update: Pseudoephedrine. Birh Defects Research Part A: Clinical and Molecular Teratology, 76(6), 445-452. Retrieved from http://onlinelibrary.wiley.com/journal/10.1002/%28ISSN%291542-0760
- Bonapace, E. S., & Fisher, R. S. (1998). Constipation and diarrhea in pregnancy. Gastroenterology Clinics of North America,27(1), 197â€“211. Retrieved from http://www.gastro.theclinics.com/
- Law, R., Maltepe, C., Bozzo, P., & Einarson, A. (2010). A treatment of heartburn and acid reflux associated with nausea and vomiting during pregnancy. Canadian Family Physician, 56(2), , 143-144.
- Kaltenbach, T., Crockett, S., &Gerson, L. B. (2006). Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Archives of Internal Medicine, 166, 965-971. doi:10.1001/archinte.166.9.965
- Organization of teratology information specialists (OTIS). (2010). Topical acne treatments. Retrieved from http://www.mothertobaby.org/files/Topical_Acne_Treatments.pdf
- Buzzo, P., Chua-Gocheco, A., & Einarson, A. (2011). Safety of skin care products during pregnancy. Retrieved from http://www.motherisk.org/prof/updatesDetail.jsp?content_id=946
- Organization of teratology information specialists (OTIS). (2010). Diphenhydramnine and pregnancy. Retrieved from http://www.mothertobaby.org/files/Diphenhydramine.pdf
- Gilboa, S. M., Strickland, M. J., Olshan, A. F., Werler, M. M., & Correa, A.. (2009).Use of antihistamine medications during early pregnancy and isolated major malformations. Birth Defects Research Part A: Clinical and Molecular Teratology, 85(2), 137-150. Retrieved from http://onlinelibrary.wiley.com/journal/10.1002/%28ISSN%291542-0760
- Gilboa, S. M., Ailes, E. C., Rai, R. P., Anderson, J. A., & Honein, M. A. (2014). Antihistamines and birth defects: A systematic review of the literature. Expert Opinion on Drug Safety, 13(12) 1667-98. doi: 10.1517/14740338.2014.970164
- Mahadevan, U., & Kane, S. (2006). American Gastroenterological Association Institute technical review on the use of gastrointestinal medications in pregnancy. Gastroenterology,131(1), 283-311. http://dx.doi.org/10.1053/j.gastro.2006.04.049
- Avsar, A. F., & Keskin, H. L. (2010). Haemorrhoids during pregnancy. Journal of Obstetrics and Gynaecology, 30(3), 231-237. doi: 10.3109/01443610903439242
- Bradley, C. S. et al (2007). Constipation in pregnancy: Prevalence, symptoms, and risk factors. Obstetrics and Gynecology, 110(6), 1351-1357. Retrieved from http://journals.lww.com/greenjournal/pages/default.aspx
- Organization of teratology information specialists (OTIS). (2010). Miconazole/clotrimazole and pregnancy Retrieved from http://www.mothertobaby.org/files/Miconazole.pdf
- Soong, D., & Einanson, A. (2009). Vaginal yeast infection during pregnancy. Retrieved fromhttp://www.motherisk.org/prof/updatesDetail.jsp?content_id=900
- Bonnet, M. H., & Arand, D. L. (2011). Patient information: Insomnia (beyond the basics). Retrieved from http://www.uptodate.com/contents/insomnia-beyond-the-basics
- Osadchy, A., Kazmin, A., & Koren, G. (2009). Nicotine replacement therapy during pregnancy: Recommended or not recommended? JOGC, 31(8), 744-747. Retrieved from http://www.jogc.com/index_e.aspx
- KonĂ©, P., Lambert, L., & Milord, F. (2005). Epidemiology and effects of infection West Nile virus on human health. QuĂ©bec, QC: National Institute of Health Public Quebec. Retrieved from: https://www.inspq.qc.ca/publications/408
- Koren, G., Matsui, D., & Bailey, B. (2003). DEET-based insect repellents: Safety implications for children and pregnant and lactating women. Canadian Medical Association Journal, 169(3), 209-212. Retrieved from http://www.cmaj.ca/content/169/3/209.full.pdf+html
- Organization of teratology information specialists (OTIS). (2013). DEET (N, N-ethyl-m-toluamide) and pregnancy. Retrieved from http://mothertobaby.org/fact-sheets/deet-nn-ethyl-m-toluamide-pregnancy/
- Sarveiya, V., Risk, S., & Benson, H. A. (2004). Liquid chromatographic assay for common sunscreen agents: Application to in vivo assessment of skin penetration and systemic absorption in human volunteers. Journal of Chromatography B: Analytical Technologies in the Biomedical and Life Sciences, 803(2), 225-231. Retrieved from http://www.journals.elsevier.com/journal-of-chromatography-b/
- Abbey, J. (2014). Over-the-counter treatments for cough and cold. Retrieved from http://www.infantrisk.com/content/over-counter-treatments-cough-and-cold#sthash.HmLJDsfP.dpuf
- The Royal Womenâ€™s Hospital. (2013). Herbal and traditional medicines in pregnancy. Retrieved from: https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Herbal-traditional-medicines-in-pregnancy.pdf
- Mils, E., Dugoua, J. J., & Perri, D., & Koren, G. (2006). Herbal medicines in pregnancy & lactation: An evidenced based approach. Toronto, ON: Taylor & Francis.
- Health Canada. (2014). About natural health product regulation in Canada. Retrieved from http://www.hc-sc.gc.ca/dhp-mps/prodnatur/about-apropos/index-eng.php
- The Royal Womenâ€™s Hospital. (2013). Herbal traditional medicines in breastfeeding. Retrieved from https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Herbal-traditional-medicines-in-breastfeeding.pdf
- loke, Y. (2010). Pregnancy and breastfeeding: Medicines guideMelbourne, Australia: The Royal Womenâ€™s Hospital, Pharmacy Department.
- Dugoua, J., Seely, D., Perri, D., Mills, E., & Koren, G. (2008). Safety and efficacy of cranberry (vaccinium macrocarpon) during pregnancy and lactation. Canadian Journal of Clinical Pharmacology, 15(1) e80â€“6. Retrieved from http://www.jptcp.com/
- Perri, D., Dougoua, J. J., Mills. , & Koren, G.(2006). Safety and efficacy of Echinacea (Echinacea angustafolia, e. purpurea and e. pallida) during pregnancy and lactation. Canadian Journal of Clinical Pharmacology, 13(3), e262-267. Retrieved from http://www.jptcp.com/
- Zapantis, A., Steinberg J. G., & Schilit, L. (2012). Use of herbals as galactagogues. Journal of Pharmacy Practice, 25(2), 222-31. doi: 1177/0897190011431636
- Koren, G., & Maltepe, C. (2014). How to survive morning sickness successfully. Retrieved from http://www.motherisk.org/women/morningSickness.jsp
- Viljoen, E., Visser, J., Koen, N., & Musekiwa, A. (2014). A systematic review and meta-analysis of the effect and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. 13(20),. doi:Â 1186/1475-2891-13-20
- Seely, D., Dugoua, J. J., Perri, D., Mills, E., & Koren, G. (2008). Safety and efficacy of panax ginseng during pregnancy and lactation. Canadian Journal of Clinical Pharmacology,15(1), e87-94.
- Sivojelezova, A., Koren, G., & Einarson, A. (2007). Glucosamine use in pregnancy: An evaluation of pregnancy outcome. Journal of Womenâ€™s Health,16, 345â€“348.
- Holst, L., Haavik, S., & Nordeng, H. (2009). Raspberry leaf – Should it be recommended to pregnant women? Complementary Therapies in Clinical Practice, 15, 204â€“208. Retrieved from http://www.sciencedirect.com/science/journal/17443881
- Dugoua, J. J., Mills, E., Perri, D., & Koren, G. (2006). Safety and efficacy of St. John’s wort (hypericum) during pregnancy and lactation. Canadian Journal of Clinical Pharmacology, 13(3), e268-76. Retrieved from http://www.jptcp.com/
- Gagnon, H. (2010). The use of psychoactive drugs among QuĂ©bĂ©cois youth. National Institute of Public Health of QuĂ©bec. Retrieved from https://www.inspq.qc.ca/pdf/publications/1102_UsageSubsPsychoativesJeunes.pdf
- Centre QuĂ©bĂ©cois de Lutte aux DĂ©pendances. (2006). Drugs: Know more, risk less. Retrieved from http://www.cqld.ca/livre/fr/qc/
- Jumah, N. A., Graves, L., Kahan, M. (2015). The management of opioid dependence during pregnancy in rural and remote settings. CMAJ, 187(1), e41-46. doi: 10.1503/cmaj.131723
- Best Start Resource Centre (2013). Prescription drug misuse in pregnancy and pregnancy: A report for service providers working with First Nations Women in Ontario. Toronto, ON: Retrieved from http://www.beststart.org/resources/rep_health/E32A_prescription_drug.pdf
- Leonard, I., & Ben Amar, M. (2002). Psychotropic drugs: Pharmacology and addiction. MontrĂ©al, QC: Les Presses of the University of MontrĂ©al.
- Schempf, A. H. (2007). Illicit drug use and neonatal outcomes: A critical review. Obstetrical & Gynecological Survey, 62(11), 749-757. Retrieved from http://journals.lww.com/obgynsurvey/Pages/default.aspx
- Morissette, P., Chouinard-Thompson, A., Devault, A., Rondeau, G., & Roux, M. (2008). The partner’s abusive consuming psychoactive substances: A key player for safety and optimum well-being of children. In P. Morissette, & M.Venne (Eds.),. Parenting, alcohol and drugs. A multidisciplinary challenge (pp. 195-217). Montreal, QC: Ă‰ditions of the CHU Sainte-Justine.
- Suchman, N., Mayes, L., Conti, J., Slade, A., & Rounsaville, B. (2004). Rethinking parenting interventions for drug-dependent mothers: From behavior management to fostering emotional bonds. Journal of Substance Abuse Treatment, 27, 179-185. http://dx.doi.org/10.1016/j.jsat.2004.06.008
- Noonan, K., Reichman, N. E., Corman, H.,& Dhaval, D. (2007). Prenatal drug use and the production of infant health. Health Economics, 16 (4), 361-384. Retrieved from http://www.nber.org/papers/w11433
- English, D. R. (1997). Maternal cannabis use and birth weight: a meta-analysis. Addiction, 92(11), 1553-1560.
- Rayburn, W.F., Billington, M. P. Pharmacotherapy for pregnant women with addictions. American Journal of Obstetrics and Gynecology, 191(6), 1885-1897. http://dx.doi.org/10.1016/j.ajog.2004.06.082
- Cook, P. S., Petersen, R. C., Moore, D. T., & Haase, T. B. (1990). Alcohol, tobacco, and other drugs may harm the unborn. Rockville, MD: S. Dept. of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, Office for Substance Abuse Prevention.
- Cressman, A. M., Natekar, A., Kim, E., Koren, G., & Bozzo, P. (2014). Cocaine abuse during pregnancy. JOGC, 36(7), 628-31. Retrieved from http://www.jogc.com/index_e.aspx
- Health and Social Services QuĂ©bec. (2009). Pregnancy: Alcohol and drugs, you need to know. QuĂ©bec, QC: Author
- Plessinger, M. A. (1998). Prenatal exposure to amphetamines. Risks and adverse outcomes in pregnancy. Obstetrics and Gynecology Clinics of North America, 25(1), 119-138. Retrieved from http://www.obgyn.theclinics.com/article/S0889-8545(05)70361-2/abstract
- Anthony, E. K., Austin, M. J., & Cormier, D.R. (2010). Early detection of prenatal substance exposure and the role of child welfare. Children and Youth Services Review, 32, 6-12.doi:10.1016/j.childyouth.2009.06.006
- Bauer, C. R., Shankaran, S., Bada, H. S., Lester, B., Wright, L. L., Krause-Steinrauf, H., â€¦ Verter, J. (2002). The Maternal Lifestyle Study: Drug exposure during pregnancy and short-term maternal outcomes. AJOG, 186(3), 487-495. http://dx.doi.org/10.1067/mob.2002.121073
- Chasnoff, I. J. (1988). Drug use in pregnancy: Parameters of risk. Pediatric Clinics of North America, 35(6), 1403-1412.
- Motherisk, CAMH. (2007). Exposure to psychotropic medications and other substances during pregnancy and lactation. Toronto, ON: Author.
- Garry, C. (2009). Cannabis and breastfeeding. Journal of Toxicology, 2009, 1-5. doi: 10.1155/2009/596149
- Committee on Drugs. (2001). The transfer of drugs and other chemicals into human milk. Pediatrics,108, 776-789.
- (2015). Lactmed: Cannabis. Retrieved from http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~9Ynv79:1
- Committee on Drugs. (2001). The transfer of drugs and other chemicals into human milk. Pediatrics, 108, 776-789.
- Bonari, L., Bennett, H., Einarson, A., & Koren, G. (2004). Risks of untreated depression during pregnancy. Retrieved from http://www.motherisk.org/women/updatesDetail.jsp?content_id=683
- Chung, T. K. H., Lau, T. K., Yip, A. S. K, Chiu, H. F. K., & Lee, D. T. S. (2001). Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosomatic medicine, 63(5), 830-834.
- Dennis, C., & McQueen, K. (2009). The relationship between infant feeding outcomes and postpartum depression: A qualitative systematic review. Pediatrics, 123(4), e736-751.
- Grigoriadis, S. (2013). Meta-analysis poor neonatal adaptation syndrome (PNAS). Journal of Clinical Psychiatry, 74(4), e309-320.
- (2014). Control of Hypertension in Pregnancy Study. Retrieved from http://www.motherisk.org/women/commonDetail.jsp?content_id=803
- Society of Obstetricians and Gynaecologists of Canada. (2014). Diagnosis, evaluation and management of hypertensive disorders of pregnancy: Executive summary. JOGC, 36(5), 416-438.
- Al-Maawali, A., Walfisch, A., & Koren, G. (2012). Taking angiotensin-converting enzyme inhibitors during pregnancy – Is it safe? Retrieved from: http://www.motherisk.org/women/drugsDetail.jsp?category_id=151&title=ACE
- Mayo Clinic. (2014). Epilepsy and pregnancy: What you need to know. Retrieved from: http://www.mayoclinic.org/healthy-living/pregnancy-week-by-week/in-depth/pregnancy/art-20048417
- Mann, D., & Johnson, T. (n.d.). How Rheumatoid arthritis affects pregnancy. Retrieved from http://www.webmd.com/rheumatoid-arthritis/features/ra-pregnancy
- Society of Obstetricians and Gynaecologists of Canada. (2002). Screening for gestational diabetes mellitus. JOGC, 121, 1-10.
- Canada Diabetes Association Clinical Practice Guidelines. (2013). Diabetes and pregnancy. Retrieved from http://guidelines.diabetes.ca/executivesummary/ch36
- (2013). Asthma during pregnancy – Topic overview. Retrieved fromhttp://www.webmd.com/asthma/tc/asthma-during-pregnancy-topic-overview
- (2008). Urinary tract infections in pregnancy. Retrieved fromhttp://www.motherisk.org/prof/updatesDetail.jsp?content_id=882
- Einarson, A., Maltepe, C., Bokovic, R., & Koren, G. (2007). Treatment of nausea and vomiting in pregnancy: An updated algorithm. Canadian Family Physician,53(12), 2109-2111. Retrieved from http://www.cfp.ca/
- Persaud, N., Chin, J., & Walker, M. (2014). Should doxylamine-pyridoxine be used for nausea and vomiting of pregnancy? Journal of Obstetrics & Gynaecology Canada, 36(4), 343-348.
- (2013). HIV treatment in pregnancy. Retrieved from http://www.motherisk.org/women/hiv.jsp
- Logan, D. E., & Marlatt, A. G. (2010). Harm reduction therapy: A practice-friendly review of research. Journal of Clinical Psychology: In session, 66(2), 201-214,doi: 10.1002/jclp.20669
- World Health Organization. (2004). Neuroscience of psychoactive substance use and dependence: Summary. Geneva, Switzerland: Author.
- College of Physicians of Quebec. (1999). Use of methadone in the treatment of opioid addiction. Retrieved from http://www.cran.qc.ca/sites/default/files/client/Ligne_directrices_CMQOPQ.pdf
- Health Canada. (2002). Best Practices Methadone Maintenance Treatment. Retrieved from https://www.canada.ca/en/health-canada/services/health-concerns/reports-publications/alcohol-drug-prevention/best-practices-methadone-maintenance-treatment.html#a94
- Centre for Addiction and Mental Health. Methadone Maintenance Treatment: Client Handbook. Chapter 7. Retrieved from http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/methadone/client_handbook/Pages/mmt_clienthndbk_ch7.aspx
- Glatstein, M.M., Garcia-Bournissen, F., Finkelstein Y., Koren. G. (2008). Methadone exposure during lactation. Canadian Family Physician, 2008, 54(12) 1689-1690. Retrieved from http://www.cfp.ca/content/54/12/1689.full