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How hot are you on... smoking and drinking during conception and pregnancy?

Test your knowledge for the nMRCGP with this little GEM from GPnotebook

Test your knowledge for the nMRCGP with this little GEM from GPnotebook

A 35 year-old-woman who is planning to conceive visits you at your surgery. This will be her third pregnancy. She has had a previous miscarriage at 10/40 four years ago and has a three-year-old daughter who was born at 41/40 via normal vaginal delivery. Her blood pressure is 120/80mmHg. She is a smoker and drinks 10 units of alcohol per week.

Q Does smoking affect a woman's fertility?

A Women who smoke should be informed that smoking is likely to reduce their fertility. They should be offered referral to a smoking cessation programme to support their efforts to stop. Women should also be informed that passive smoking is likely to affect their chance of conceiving.

Q If this woman was given smoking cessation medication, is nicotine replacement therapy (NRT) or bupropion advised in pregnancy?

A Women who are pregnant or breastfeeding should not use bupropion. Pregnant women who smoke should be informed of the risk of smoking to the foetus and themselves and encouraged to stop (for instance by referral to a smoking cessation service).

It is preferable to stop smoking without NRT if pregnant, but if this is not possible, NRT may be recommended to assist a quit attempt, as it is considered less harmful to the foetus than continuing to smoke.

A retrospective cohort study in Denmark raised concerns about an increased risk of congenital malformations when using NRT in pregnancy. However there was no direct evidence or plausible explanation for the apparent increased risk with NRT when compared with smoking because of the small number (19) of malformations in children of women using NRT relative to other non-smokers (2,719).

The study was statistically underpowered to detect the difference, which may have occurred by chance as the study was observational and the results may have been influenced by uncontrolled confounding factors.

The following advice has been issued by Action on Smoking and Health (ASH) with respect to the use of NRT in pregnancy and the findings of the Danish study: 'Pregnant smokers should always be encouraged first to give up smoking without using NRT.

However, these research findings do not mean that pregnant smokers are better off smoking than using NRT. The risks of premature birth or stillbirth caused by smoking are far higher than any potential higher risk of congenital malformation caused by NRT use.'

Q What are the concerns regarding alcohol consumption and pregnancy? Is there a 'safe' daily alcohol limit?

A The critical dose for alcohol consumption during pregnancy has not been determined.

It is believed that 'binge' drinking has more detrimental effects on the fetus than a background alcohol consumption.Alcohol consumption is associated with symmetrical growth retardation.

Alcohol influences fetal development particularly in the first trimester.Excessive alcohol intake is associated with the development of fetal alcohol syndrome.NICE states that women should limit alcohol consumption to no more than one standard unit per day.

This series is based on GPnotebook Educational Modules (GEMS). The full version is available via GPnotebook Pulse, a service free to UK medics at gpnotebook

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