Fetal risks associated with alcohol, marijuana, cocaine, amphetamines, and heroin are discussed in Chapter 12 (p. 239). he first step in preventing drug-related fetal risk is an honest assessment of use by the patient (American College of Obstetricians and Gynecologists, 2017 c) . Toward this end, questioning should be nonjudgmental. Screening for at-risk drinking can be accomplished using several validated tools. One is the wellstudied T ACE questions (American College of Obstetricians and Gynecologists, 2013). This is a series of four questions concerning .olerance to alcohol, being 4nnoyed by comments about their drinking, attempts to fut down, and a history of drinking early in the morning-the fye opener.
In a Canadian study of more than 1000 postpartum patients, Tough and coworkers (2006) found that a high percentage of women reported alcohol use concurrent with conception attempts. Specifically, nearly half of those planning for pregnancy reported a mean of 2.2 drinks daily during early gestation and before they recognized their pregnancy. Of note, Bailey and associates (2008) found that rates of binge drinking and marijuana use by men were unafected by their partner's pregnancy. The frequency and pattern of such behaviors clearly underscore the opportunity for preconceptional counseling.
Currently 20 million women in the United States smoke cigarettes (Centers for Disease Control and Prevention, 2014). Smoking in pregnancy has been consistently associated with numerous adverse perinatal outcomes, listed in Chapter 12 (p. 249). These risks are largely mitigated by cessation before pregnancy, highlighting the importance of screening for tobacco use in the preconceptional period and during prenatal care as outlined in Chapter 9 (p. 161).
Contact with environmental substances is inescapable. Thus, it is fortunate that only a few agents have been shown to cause adverse pregnancy outcomes (Windham, 2008). Exposures to infectious diseases have myriad deleterious efects, and these are detailed in Chapters 64 and 65. Likewise, contact with some chemicals may impart signiicant maternal and fetal risks. As discussed in Chapters 9 and 12 (pp. 170 and 244), excess exposure to methyl mercury or lead is associated with neurodevelopmental disorders.
In the past, some concerns were raised over common everyday exposure to electromagnetic iels such as those emanated by high-voltage power lines, electric blankets, microwave ovens, and cellular phones. Fortunately, no human or animal evidence links these and adverse fetal outcomes (Robert, 1999). he efects of electrical shock are discussed in Chapter 47 (p. 930).
Pica is the craving for and consuming of ice, laundry starch, clay, dirt, or other nonfood items. It should be discouraged due to its inherent replacement of healthul food with nutritionally empty products (Chap. 9, p. 174). In some cases, it may represent an unusual physiological response to iron deficiency. Many vegetarian diets are protein deficient but can be corrected by increasing egg and cheese consumption. Anorexia and bulimia increase maternal risks of nutritional deiciencies, electrolte disturbances, cardiac arrhythmias, and gastrointestinal pathology (Becker, 1999). s discussed in Chapter 61 (p. 1180), pregnancy-related complications with these disorders include greater risks of low birthweight, smaller head circumference, microcephaly, and small-for-gestational-age newborns (Kouba, 2005).