Women users of drugs of abuse during pregnancy : characterization of a series of cases

This study characterized the sociodemographic and obstetric profile of women users of drugs of abuse during pregnancy. This is a descriptive and exploratory study, whose approach technique was the document records analysis of toxicological occurrence and medical charts of 32 women referred to a center for information and toxicological assistance of the Paraná State, between 2008 and 2010. The data were subjected to descriptive statistics. Most women had between 15 and 24 years (59.4%), between the first and third gestation, without prenatal care, poorly educated, without paid occupation (93.8%), and were in a common-law marriage (50%). Tobacco was used by 27 women (84.4%), crack by 24 (75%), and alcohol by 23 (71.7%). Besides the habitual use of drugs of abuse, it also stood out as risk factors before the pregnancy: teenage pregnancy, insecure marital status, and low education. As for the risks during the pregnancy, the most important clinical and obstetric problems were associated with addictive behavior. The sociodemographic profile corroborated the literature, but the multiparity, the low adhrence to the prenatal care, the multiuse of drugs, and the high number of complications, have indicated problems of health services to reach these women, resulting in a prolonged stay length, increased use of neonatal beds, and neonatal death.


Introduction
Problems related to the consumption of alcohol and other drugs of abuse are most common in men, which have guided the planning, and health and social interventions especially to male needs, disregarding the differences between the sexes, whether physiological, psychological or social (OLIVEIRA et al., 2006).
Changes in the woman's social role and higher availability of drugs in the society caused the decrease in the ratio between the sexes, mainly among younger, with largest the drop in the age of start using substances among women.Users of drugs of abuse comprise a distinct group with own features and requirements, both in relation to diagnosis, treatment and prevention (WAGNER et al., 2007;YAMAGUCHI et al., 2008).
A study performed in the last decade pointed that 51% of women of reproductive age had already used alcohol, 29, tobacco, 7, marijuana, and 1, cocaine, and that 8% had used some psychoactive substance in the last month.Women users of drugs presented higher prevalence of psychiatric comorbidities (YAMAGUCHI et al., 2008).Oliveira and Nappo (2008a) observed the trend among individuals that have passed from the compulsive use of drugs to a controlled pattern, as a way of self-regulation of the own user.This pattern usually takes place on the turning points, which are significant events in the life that tend to favor the discontinuation of drugs, being relevant to detect the moments of life when the health, social and cultural devices, other than formal treatments, exist as supporters for the amendment of the exclusive relationship with the drug.
Pregnancy may meet this turning point, although, it is evident that the lack of monitoring during pregnancy by health workers, poor diet, lack of family support, and drug use during pregnancy leads to preterm birth, low birthweight and other neonatal complications (RODRIGUES; NAKANO, 2007;YAMAGUCHI et al., 2008).
The nurse, as a member of the health staff and coordinator of nursing team, is qualified to welcome pregnant women users of drugs of abuse and should prepare the nursing team and community health workers to deal with this phenomenon in the community, aiming to promote the health care and harm reduction.
There are several risk factors for pregnancy, and some can be present before the pregnancy.As risk markers and factors before the pregnancy we may cite: previous reproductive history, and pre-existing clinical conditions; individual characteristics of the mother and unfavorable sociodemographic conditions -age ≤ 15 or ≥ 35 years, height, weight, insecure marital status, family conflicts, low education, unfavorable environmental conditions, exposure to occupational risks and to harmful physical, chemical and biological agents, stress, and dependence on licit or illicit drugs (BRASIL, 2010).
A research conducted with a thousand pregnant teenagers attended in a hospital of the state of São Paulo, in labor and/or for curettage, revealed a behavioral profile of drugs use during pregnancy: 173 teenagers smoked, on average, five cigarretes/day (17.3%), ranging from one to 50; 266 teenagers admitted to having drunk alcohol at least on one occasion during pregnancy (26.6%), and 28 of them abusively (2.8%); and 17 said to having used marijuana and powder cocaine during pregnancy (1.7%) (CHALEM et al., 2007).
In many ways, women users of illicit drugs are hidden from society, whether by using an illegal drug and by social criminality related, or by the stigma of issues inherent to 'feminine', such as maternity, care of children and family, and continuity of drug use in pregnancy.They can be found in specialized treatment of chemical addiction, where are admitted for recovery or by overdose; in police stations, jails and prisons, where they are due to the drug-related crimes; and in hospitals because of the violence, or for health care by drugs or other conditions related to them (comorbidities) (WAGNER et al., 2007;MARANGONI;OLIVEIRA, 2012).
Considering that the phenomenon 'drugs of abuse' in women has been influenced by economic, social and cultural processes of the different societies, it becomes necessary to know the socio-demographic profile of these women 'hidden from society', as a way to subsidize and support the development of health actions, in particular of nursing, that welcome and link this population subgroup (WRIGHT; CHISMAN, 2004).
Knowing the pattern of use, the trajectory of drugs use, the dependence stage, and the intervening factors may be an effective tool to understand this phenomenon and aims establishing interfering strategies with the highest chances of success (OLIVEIRA; NAPPO, 2008b).
It draws attention the little change in the behavior of drug users during pregnancy, since the pregnancy was not enough to make them abandon the drug.Although the use of drugs of abuse is considered as little influenced by the intervention of health services, once it is associated with multiple social factors, pregnant drug users are less assisted by the prenatal care, when it would be provided chances and guidances for abstinence or harm reduction, and present higher incidence of complications during pregnancy.
Given the above, this study aimed to characterize the sociodemographic and obstetric profile of women users of drugs of abuse during pregnancy, knowing the use of illicit or licit drugs as a gestational risk factor before the pregnancy and the pregnancy as a turning point (OLIVEIRA; NAPPO, 2008a;BRASIL, 2010).

Material and methods
This is a descriptive and exploratory study, with retrospective data of a series of cases of women users of drugs of abuse, using the document record analysis as approach technique.
A case series study is used to describe characteristics of human health, employed to a group of ten or more people with a particular health problem, being common the retrospective analysis of individual's life (FLETCHER et al., 2007).
Using documents in research enables adding the time dimension to the social understanding and favor the observation of the maturation or evolution of individuals, groups, concept, knowledge, behaviors, attitudes, practices, among others (CELLARD, 2008).
The object of study was composed by 32 medical records of women with secondary medical diagnosis and/or nurse´s evolution records for acute or chronic intoxication by drugs of abuse during pregnancy.The women lived in the municipalities belonging to the 15 th Health Regional Management (HRM) -Paraná State and reported to the Center for Intoxication Control of a University Hospital -Maringá (CCI/HUM), between January 2008 and December 2010.
Maringá is the third largest city of Paraná State, and headquarter of the 15 th HRM the with an estimated population of 357,077 inhabitants.The occurrence of cases in the small municipalities in the Northwestern region of Paraná State -Itambé and Paranacity, with 5,979 and 10,250 inhabitants respectively, points out the trend of supply and consumption of drugs of abuse in smaller cities (IBGE, 2011).
As data sources, it was used epidemiological records of Toxicological Occurrence, a tool to record all cases of intoxication treated in the CCI/HUM, of which were collected data of identification of the woman, and of the toxicological event; the hospital records of the women, where it was possible to obtain by the nursing and medical records, the reproductive history of the women and the risk markers and factors present before the pregnancy, obstetric and perinatal information related to the current pregnancy, and the conditions and complications that emerged during the pregnancy.
We examined the individual and sociodemographic characteristics of the women (age group, marital status, education, occupation, municipality of residence); the pattern of drugs use, the circumstances of admission (reason and period of admission, evolution and clinical outcome); obstetric and neonatal characteristics (number of pregnancies, number of prenatal visits, gestational age, route of delivery, obstetric conditions, and complications that arouse during pregnancy).
The data were collected in March and April 2011, entered into a digital spreadsheet, managed, and analyzed by the software Epi Info, and subjected to descriptive statistics.It was calculated the conventional measures of central location -mean, median and/or mode, for the variables: cases/year, age, education, admission period, number of pregnancies, association of the risk factors in the current pregnancy.
The study was submitted to the Research Ethics Committee on Human Beings of the State University of Maringá and approved under Legal Opinion n. o 065/2011.Since these are secondary data, we requested waiver of the Consent Form.

Results and discussion
Of the 32 women users of drugs of abuse during the pregnancy puerperal cycle, only one was admitted in the immediate postpartum: a vaginal delivery occurred in the street, with gestational age of 34 weeks and four days.Twenty-five (78.1%) were admitted in the Unit of Obstetrics and Gynecology, and seven (21.9%) into the Emergency Department of the HUM.
The ratio cases/year varied between five and 15 cases, with average of 11 cases per year.They came from 11 of the 30 municipalities of the catchment area of the 15 th Health Regional Management (36.7%), but the municipality of Maringá had the highest number of notifications, with 18 cases (56.2%), followed by Sarandi, with three (9.5), and Itambé and Paranacity, with two cases (6.2%) each.
The increase of drug users in small cities may be associated with criminals' strategies to increase the consumer market, and a result of the crackdown actions in the large centers.As increases the pressure and the combating trafficking points in large municipalities, the trafficking seek elsewhere for distribution, where the repression is lower (OLIVEIRA; NAPPO, 2008b).Nevertheless, the small municipalities are not prepared to face the phenomenon at short or medium term, given the lack of anti-drug municipal councils and centers for treatment and rehabilitation to assist the users.
The age of the women ranged from 16 to 42 years, but most of them were in the age group of 16-24 years (59.4%).The average age was 24.5 years (Table 1).
Eight cases of pregnancy occurred during the adolescence.The maternity during the adolescence restricts the educational and professional options of the woman, contributing to the maintenance of socioeconomic deprivation conditions.The teenagers that fail to complete their studies will consequently have lives of economic depression, with increased risk of exposure to prostitution and marginality due to drug addiction (PELLOSO et al., 2008;OLIVEIRA;NAPPO, 2008a).
Among the gestational risk markers and factors before the pregnancy, stands out the insecure marital status (BRASIL, 2010).As a condition linked to the pregnant's age, the series of cases is characterized by single women or living in common-law marriage, with informal and rotating marital relationship, considered head of their families (Table 1).Between 1998 and 2008, the women participation in the labor market increased 5.2%, the percentage of women who work in Brazil is higher than in European countries.But 44.7% of children and adolescents live with a per capita family income of half the minimum wage, and 18.5% with ¼ of the minimum wage, under extreme poverty (IBGE, 2009).The families headed by women are more vulnerable and have worst indicators of access to the knowledge and work.In this group, predominate the families where the head has no occupation, and when has, it is in the informal sector (BARROS et al., 2006).
Among the 27 women that informed the education level (84.4%), none had the schooling compatible with the age; the mode was the fifth grade of elementary school (5).Most of them went to school for a period of four to seven years and only one reported that still go to school (Table 1).
Studies performed with young and adolescent revealed that the regular attendance to the school is a protective factor against the use of drugs of abuse, since the truancy and low education were determinant in the continued use of drugs (BALLANI;OLIVEIRA, 2007;BRUSAMARELLO et al., 2010) Coupled with poor education, the occupation of the women pointed out that 30 did not perform any paid occupation (93.8%): 18 declared as being housewives, and 12 as unemployed.Among the unemployed pregnant women, two were deprived of civil liberty, serving a sentence for involvement in drug trafficking, and six were homeless, or transiting in the street, at the time of admission (Table 1).
The alcohol and other drugs are part of the streets' reality, either as an alternative to minimize hunger and cold, whether as an element of socialization among the group members of the street, being considered one of the cultural dimensions that make up the lifestyle of the street's population.Besides the difficulties inherent of being homeless, the health services are not prepared to welcome this population, including pregnant women, especially teenagers, which cannot rely on adequate care in the assistance places (COSTA, 2005).
The unfavorable socioeconomic condition associated with the inappropriate housing conditions, lack of poor education, unemployment or underemployment, and other conditions, including poverty contribute to increase the violence, and direct or indirect participation in trafficking and crime (MARÍN-LEÓN et al., 2007).
Drugs, gestational risk factors before the pregnancy, were used by the women under additive sequential behavior, and the pattern of use started by the low toxicity drugs, tobacco and alcohol, followed by illicit drugs (BRASIL, 2010;SELEGHIM et al., 2011).
In relation to the use pattern of drugs of abuse, the analysis pointed out that the first illicit drugs consumed were tobacco, in 25 cases (78.1%), and alcohol in six (18.7%).The marijuana was pointed by 15 women (53.1%) as the first illicit drug, and only one reported to having used powder cocaine as starting drug (12.5%).Only one pregnant pointed the crack as the first and only drug used, but it was the most used illicit drug during pregnancy -24 women (75%).
Tobacco, crack and alcohol, the most used drugs in the studied population, easily cross the placental barrier, and as consequence for the pregnant woman, there is greater incidence of abruptio placentae, premature rupture of membranes and intrauterine growth retardation.Moreover, the active principle of marijuana, the delta-9-tetrahydrocannabinol (THC) is highly lipid soluble, and easily crosses the placental barrier causing maternal and fetal alterations (BRADY, 2007;YAMAGUCHI et al., 2008 Cocaine, whose hydrochloride can be consumed in various ways -sucked in powder, intravenous dissolved in water, in the form of base (crack or merla), smoked in pipes, crosses rapidly the placental barrier without being metabolized, acting directly on fetal vasculature, causing vasoconstriction and fetal malformations (YAMAGUCHI et al., 2008;MARANGONI;OLIVEIRA, 2012).
The woman's age and the type of drug used are pointed as distinguishing factors among women users of drugs.In general, the teenagers besides consuming alcohol, use illicit drugs like marijuana, cocaine and crack, while adult women prefer cigarretes, alcohol and medications, especially tranquilizers and appetite suppressants (OLIVEIRA et al., 2007;SELEGHIM et al., 2011).
A study undertaken with users of crack pointed the tobacco and alcohol as the licit drugs of first use, and in the sequence, the marijuana already consumed during the adolescence.There is association between the use of some substances, user's age, living environment, socioeconomic conditions, and trafficking influence, which in the case of Brazil, had a determinant role on imposing some drugs (OLIVEIRA; NAPPO, 2008b;SELEGHIM et al., 2011).
Around 10% of North-American women that used powder and/or alkaline cocaine during pregnancy, presented complications such as premature birth, abruptio placentae, and other perinatal complications, favoring the hospitalizations (YAMAGUCHI et al., 2008).
Pregnant women who did not seek prenatal care are at higher risk of continuing drug use during pregnancy.A biological test to test drugs in urine of 50 pregnant women that did not attend prenatal care, revealed 52% of positive tests for cocaine, 14% for opioids, 8% for marijuana (tetrahydrocannabinol) and amphetamines.Of the 26 positive samples for cocaine, six (23%) were also positive for opiates and four (15%) positive for amphetamines (BIRNBACH et al., 2001).
The admission circumstances were classified by the criteria set to determine the pregnancy risk factors (BRASIL, 2010) and indicated that 18 women, when admitted in the HUM, presented complications that allowed classifying them as high-risk pregnant (56.2%).Among them, ten had obstetric diseases in the current pregnancy (31.2%) -seven were under preterm labor (21.8%) and three with fetal death (9.4%); and three presented clinical events (9.4%)urinary tract infection.Five pregnant women were hospitalized for external causes/violence (15.7%)two victims of domestic violence, two with polytrauma, and one with acute alcohol intoxication (Table 2).Regarding the evolution of the hospitalization, nine women performed gynecological/obstetric treatment, and four were submitted to surgical/orthopedic treatment.In 19 pregnant women, the pregnancy was interrupted by cesarean section and/or induction of vaginal delivery (Table 2).
Determining the route of delivery and the ideal time for this event in the pregnancies are dilemmas experienced by the doctor or midwife nurse, and the decision is affected by the assessment of the pregnant woman and fetal vitality.The risk pregnancy is not synonymous of cesarean section, since it is frequently possible to induce the labor aiming the natural childbirth, or wait for the spontaneous onset (BRASIL, 2010).
Of the 19 childbirths, seven women arrived at effective labor and progressed to vaginal delivery, and for six, the childbirth occurred prematurely.The chosen method to interrupt the other pregnancies was the cesarean section (63.1% -Table 2).
Brazil has one of the greatest incidences of cesarean sections worldwide, although the World Health Organization (WHO) states that the rate should remain between 10-15% of total hospital childbirths and should not exceed 30% of risk pregnancies; statistical data of the Paraná State indicate that in 2004, the index was 49% of cesarean section.This method, despite of being indicated for high-risk pregnancies, is considered by WHO as one of the most frequent practices with inadequate indication to interrupt a pregnancy (CAMPANA; PELLOSO, 2007) The hospital discharge to the mother that underwent vaginal delivery, without abnormalities observed in both mother and child, can be granted within 24 hours, and to those submitted to surgical delivery, within 48 hours (BRASIL, 2006).Nevertheless, the admission period found in the series of cases was longer, varying between one to 13 days.The mean hospital admission was 4.2 days, and the mode was three days for ten cases (Table 2).
In the cases with a long admission period, we sought the reason for this.Of the nine women that remained hospitalized for up to seven days, six were puerperal women, and two were under clinical treatment of a urinary tract infection; and for five women that exceeded eight days (15.6%), four were in the puerperium and one under clinical/obstetric treatment for preterm labor/urinary tract infection.
Several factors make the urinary tract infection a relevant complication during pregnancy, aggravating both the maternal and perinatal prognosis.For many years, the pregnancy was seen as a predisposing factor for all forms of urinary tract infection.Nowadays, the pregnancy as an isolate event is not responsible for the highest incidence; anatomical and physiological changes imposed to the urinary tract by the pregnancy predispose the asymptomatic women to pregnant women symptomatic to urinary tract infection (DUARTE et al., 2008).
In general, the maternal complications of urinary tract infection are secondary to the tissue damage caused by bacterial endotoxins, mainly occurring in the pyelonephritis.Among the perinatal complications, stand out the labor and preterm births, low birth weight infants, premature rupture of membranes, intrauterine growth retardation and perinatal death.Pregnancies complicated by urinary infection are also associated with increased fetal mortality (DUARTE et al., 2008).
At hospital discharge, all received a referral to primary health care units.Only in one case the outcome was hospital transfer -a pregnant 24-year-old homeless woman, with polytrauma, which returned to the local hospital for treatment of crack addiction (Table 2).
The monitoring by the health staff is extremely important, since it is known that is really difficult for the postpartum addict to maintain their maternal identity, once the effect of drugs may influence their behavior and ability to perform daily activities, with themselves and with the newborn.When they go out in search of drugs, many leave the children alone for long periods.Furthermore, many of them have difficulties to perform maternal tasks, because they had little positive contact with their mothers, grew up in a conflicting family environment, and not have the daily presence of a companion (ROLDÁN et al., 2005).
It should be considered, at hospital discharge of women users of drugs, the referral to reproductive planning programs, since most of them have sex without protection, keep addictive behavior in postpartum and have several risk factors for unintended pregnancy and multiparity.The health team should work with counseling strategies aiming the harm reduction with a view to family/reproductive planning, considering that these actions as well as the prenatal, are part of the main health care under the responsibility of municipalities (BRASIL, 2004).
The number of pregnancies/woman ranged from one to eight, and the mode was two pregnancies in 11 pregnant women.Two of them stand out, aged less than 30 years and history of eight pregnancies; one of them was homeless, evidencing the lack of access to reproductive planning (Table 3).The care of pregnant women addicted to alcohol and other drugs is complex and requires technical and psychosocial skills of health professionals.The main barrier in the monitoring of addicted women is the prejudice, and when pregnant, this prejudice is multiplied, so they tend not to report drug use during pregnancy (WAGNER et al., 2007;YAMAGUCHI et al., 2008;MARANGONI;OLIVEIRA, 2012).
As pregnant users of drugs of abuse, they seek less prenatal care and are prone to hide the use, especially alcohol, tobacco and cocaine, hindering the precise estimation of the gestational age (GA) (MARANGONI;OLIVEIRA, 2012).
Considering that 21 women did not attend any prenatal visit (65.5%), hindering the precise estimation of the gestational age, it was verified that 30 were between the seventh and 41 st gestational week.Most of them were approximately between the 32 nd and 41 st gestational week (Table 3).
The calculation of the GA was performed by the characteristics of newborns (NB), by Capurro.Among the premature (31.5%), the GA varied between 32 nd week and five days and 36 th week and one day, and 13 NB were considered full-term infants (68.4%) with GA between the 37 th and 41 st gestational week.
The assessment of the GA of NB by means of Capurro is based on physical aspects that mature with advancing fetal age, as progressive firmness of the ear pavillion, increased volume of breast tissue, decrease in thin and lanugo-type hair on the back, and reduced skin the signs are evaluated during the first day of life, by assigning grades, and the cumulative value is correlated with the GA and this correlation is usually accurate, and can determine whether the pregnancy was pre-term or term (SANTOS et al., 2006).
A pre-term pregnancy has a GA between the 22 nd (or 154 days) and 37 th weeks (or 259 days), associated with maternal or obstetric factors (previous premature childbirths, multiple pregnancy, premature rupture of membranes, polyhydramnios, urinary tract infection, vaginal infections) or behavioral factors (smoking, alcoholism, and other drugs of abuse), inadequate eating habits, traumas, fetal and placental abnormalities, adverse socioeconomic conditions that favor the complications (BRASIL, 2010).
Although prevention of prematurity remains a challenge for Obstetrics, some results have been achieved through identifying and treating genital and urinary tract infections in prenatal care, found in 9.4% of the studied women (BRASIL, 2010).
Only one pregnant attended to the number of prenatal visits recommended, and was accompanied at the clinic of High Risk Pregnancy of the HUM.Eleven women held consultations during pregnancy (34.4%), eight attended two appointments in emergency services, related to complications in the pregnancy (Table 3).
The timetable set by the Program for Humanization during Prenatal care and Childbirth predicts monthly visits until the 33 rd week, fortnightly visits from the 34 th to 38 th week, and weekly from the 39 th to 40 th week, and every three days after the 40 th week, with maximum limit of up to 42 weeks.Pregnant women without risk factors should attend at least six visits along the gestation.The risk factors present before the pregnancy and the complications that may arise along the gestation must be identified in the prenatal care, and the women should be referred to the assistance adequate to their situation (BRASIL, 2006;2010).
During the hospital admission, four pregnant women had symptoms consistent with withdrawal syndrome, but we cannot assure that the others were abstinent from drugs or have had developed strategies for maintaining continuing patterns of drug use at moderate levels, considering the hospitalization length and the average period of the interval in drug use to present the clinical signs of withdrawal.It was identified an attempted suicide, in a pregnant woman in the first trimester of pregnancy, with cleaning solution (sodium hypochlorite) and the woman was diagnosed with anxiety disorder and depression.
The weight of nine newborns was lower than 2,500 g, and the Apgar index was 05/08 in 10%, considered good values, indicating absence of hypoxia in the neonate when presenting a score from 8 to 10.The decreased placental flow is one of the major factors accounting for the low birth weight and is considered an indicative of the quality of reproductive health assistance to the woman, once the causal factors are likely to control under adequate care to woman at reproductive age, and is closely related to infant mortality (YAMAGUCHI et al., 2008).The withdrawal symptoms, mainly the combination hyporeactivity/hypoglycemia, were presented by nine newborn infants, and five required a neonatal ICU, and one has progressed to death.

Final considerations
Most women were at reproductive age, between 15 and 24 years, education level below the expected to the age, and out of the labor market, corroborating the literature data that associates the drug use with poverty, situations of extreme vulnerability and social exclusion.
This sociodemographic profile is compatible with the literature on the subject, but some characteristics of the series of cases, as the multiparity, the low adherence to prenatal care, multiuse of drugs during pregnancy and the high number of clinical-obstetric complications, have indicated the difficulty of health services to reach these women resulting in a prolonged stay length, increased use of neonatal beds, and neonatal death.The consequences of the abusive use of alcohol and other drugs are not well considered by the population by the ambivalent attitudes and the stigma related to the use and user, present in several cultures and social classes, evidenced in this study by the lack of prenatal and difficulty of services to reach the pregnant women users of drugs.
Taking into account that the pregnancy is a significant event that tends to favor to abandon the drug, the prenatal health care should work as supporters to change the exclusive relationship with the drug, encouraging withdrawal strategies or patterns of maintenance at moderate levels.
As for the drugs used during pregnancy, it was evidenced the sequential addictive behavior, especially tobacco, alkaline cocaine (crack), alcohol, and marijuana.With the diversity of drugs and the expansion and complexity involving the drug use in the feminine universe, there is a need to prevent this trajectory of using drugs by this group, emphasizing women at reproductive age, considering the complications for mother and child.
Besides the habitual use of drugs of abuse, the pregnancy during adolescence, insecure marital status and poor education are among the risk factors before pregnancy.Moreover, during the gestation, stand out the clinical-obstetric complications associated with the use of drugs of abuse.
The high parity was a remarkable characteristic, mainly because of the young age of this population at reproductive age, and the drug use in the adolescence associated with unwanted or unplanned pregnancy.This result indicates the need for strategies aiming reproductive and family planning.
It is important to stress the need to sensitize the health team to notify the occurrence of acute or chronic toxicological occurrence and the importance of reference and counter-reference services aiming the harm reduction after discharge.There were three cases in which pregnant women were reported under two different circumstances, and in two of them, the users returned to the hospital, again pregnant.
Although it is recognized the limitations of this study, once the data were collected by document analysis, our findings enabled to observe the phenomenon impact on female population at reproductive age, and the problems related to maternal and child health.
It is believed that the early detection by the family health professionals will permit these women to be welcome in the system and favor the recognition of pregnancy as a turning point to ease the adherence and treatment of chemical addiction, minimizing the obstetric complications, promoting harm reduction and quality of life to the mother and to the newborn.

Table 3 .
Distribution of the pregnant women users of drugs of abuse, according to obstetric variables.CCI/HUM, Maringá -Paraná State, 2011.