ABSTRACT. Substance abuse in pregnancy has increased over the past three decades in the United States, resulting in approximately 225,000 infants yearly with prenatal exposure to illicit substances. Routine screening and the education of women of child bearing age remain the most important ways to reduce addiction in pregnancy. Legal and illegal substances and their effect on pregnancy discussed in this review include opiates, cocaine, alcohol, tobacco, marijuana, and amphetamines. Most literature regarding opiate abuse is derived from clinical experience with heroin and methadone. Poor obstetric outcomes can be up to six times higher in patients abusing opiates. Neonatal care must be specialized to treat symptoms of withdrawal. Cocaine use in pregnancy can lead to spontaneous abortion, preterm births, placental abruption, and congenital anomalies. Neonatal issues include poor feeding, lethargy, and seizures. Mothers using cocaine require specialized prenatal care and the neonate may require extra supportive care. More than 50% of women in their reproductive years use alcohol. Alcohol is a teratogen and its effects can include spontaneous abortion, growth restriction, birth defects, and mental retardation. Fetal alcohol spectrum disorder can have long-term sequelae for the infant. Tobacco use is high among pregnant women, but this can be a time of great motivation to begin cessation efforts. Long-term effects of prenatal tobacco exposure include spontaneous abortion, ectopic pregnancy, placental insufficiency, low birth weight, fetal growth restriction, preterm delivery, childhood respiratory disease, and behavioral issues. Marijuana use can lead to fetal growth restriction, as well as withdrawal symptoms in the neonate. Lastly, amphetamines can lead to congenital anomalies and other poor obstetric outcomes. Once recognized, a multidisciplinary approach can lead to improved maternal and neonatal outcomes.

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Limited data are available on the attitudes of gynecologists regarding mode of hysterectomy for benign indications. This cross-sectional study used a postal questionnaire to assess attitudes of members of the Swedish Society of Obstetrics and Gynecology toward mode of benign hysterectomy. The choices of mode of hysterectomy were total abdominal hysterectomy, subtotal abdominal hysterectomy, laparoscopic or laparoscopically-assisted hysterectomy, and vaginal hysterectomy (VH). Participants were asked questions about their gender, seniority, place of work, and surgical experience, including years in the specialty and annual number of hysterectomies performed to determine whether differences in such factors influenced their choice of mode. The gynecologists were asked to choose between these modes for 3 scenarios with different benign clinical conditions. Scenario A was a normal to slightly enlarged uterus with no uterine descensus and no previous cervical dysplasia. Scenario B differed from the first scenario only in that there had been previous treatment of cervical dysplasia up to moderate degree (CIN II). In scenario C, there was an enlarged uterus (larger than gestational week 12-13) with no uterine descensus and no previous cervical dysplasia. The respondents were also asked to give their personal view of how the overall distribution should be for the different modes of benign hysterectomy. Multiple logistic regression and multivariate models of covariance were used for unadjusted and adjusted analyses.The participants chose VH in general or when the uterus was of normal size or slightly enlarged (scenarios A and B), and recommended abdominal hysterectomy and subtotal abdominal hysterectomy when the uterus was enlarged (scenario C). More male gynecologists than female gynecologists favored VH as a personal preference. There were significant variations in choice and suggested distribution of mode for place of work, seniority, and annual number of hysterectomies performed. More than 50% of the participants recommended the minimally-invasive methods of vaginal and laparoscopic hysterectomy as their overall personal choice for suggested distribution.These findings indicate that choice of mode of hysterectomy for benign conditions among gynecologists is significantly influenced by personal preference based on differences in gender, place of work, seniority, and annual number of hysterectomies, and does not appear to strictly follow evidence-based recommendations. EDITORIAL COMMENT(Hysterectomy is one of the most common operations done in the United States. These days there is quite a variety of techniques for hysterectomy and we have discussed the advantages of one approach or another on these pages many times. As I analyze the results of this article on hysterectomy preferences from Sweden, I think there are 3 different levels of preferences for types of hysterectomy:(1) what is your "theoretical" preference? (this study, where you respond to a hypothetical scenario);(2) what is your "actual" practice? (what was t...

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