Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-586b7cd67f-l7hp2 Total loading time: 0 Render date: 2024-11-22T14:07:03.706Z Has data issue: false hasContentIssue false

Chapter 25 - Substance Use Disorder

Published online by Cambridge University Press:  26 January 2024

By
Grace Lim
Edited by
David R. Gambling ,
M. Joanne Douglas  and
Grace Lim
David R. Gambling
Affiliation:
University of California, San Diego
M. Joanne Douglas
Affiliation:
University of British Columbia, Vancouver
Grace Lim
Affiliation:
University of Pittsburgh
Get access

Summary

Perinatal substance use disorder is a chronic medical condition affecting between 2-5% of the population, characterized by uncontrolled use of a particular substance despite harmful consequences. Substance use disorder is increasing in frequency in the United States, particularly among women of reproductive age. It is associated with increased risk for fetal-neonatal conditions such as growth restriction, fetal alcohol syndrome, and neonatal abstinence syndrome and places patients at risk for morbidity and mortality. In this chapter, several specific substances are considered in the context of pregnancy.

Keywords

substance usesubstance use disorderswomenpregnancy
Type
Chapter
Information
Obstetric Anesthesia and Uncommon Disorders , pp. 413 - 420
Publisher: Cambridge University Press
Print publication year: 2024

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

ACOG. ACOG Committee Opinion 711: Opioid use and opioid use disorder in pregnancy. Obstet Gynecol 2017;130:e81–e94.Google Scholar
Substance Use Disorder: APA Dictionary of Psychology; 2021. https://dictionary.apa.org/substance-use-disorder [last accessed October 2, 2022].Google Scholar
National Survey on Drug Use and Health (U.S.), United States, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Center for Behavioral Health Statistics and Quality (U.S.). Results from the 2012 National Survey on Drug Use and Health: summary of national findings. Rockville (MD): Substance Abuse and Mental Health Services Administration, 2013:1 HHS publication no (SMA) 13–4795.Google Scholar
Sander, SCE, Hays, LR. Prescription opioid dependence and treatment with methadone in pregnancy. J Opioid Management 2005;1:91–97.Google Scholar
Vesga-López, O, Blanco, C, Keyes, K, et al. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 2008;65:805–815.Google Scholar
Ebrahim, SH, Gfroerer, J. Pregnancy-related substance use in the United States during 1996–1998. Obstet Gynecol 2003;101:374–379.Google Scholar
Terplan, M, Smith, EJ, Kozloski, MJ, et al. Methamphetamine use among pregnant women. Obstet Gynecol 2009;113:1285–1291.Google Scholar
Humeniuk, R, Ali, R, Babor, T, et al. A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries. Addiction 2012;107:957–966.Google Scholar
McHugh, RK, Wigderson, S, Greenfield, SF. Epidemiology of substance use in reproductive-age women. Obstet Gynecol Clin North Am 2014;41:177–189.Google Scholar
O’Connor, E, Rossom, RC, Henninger, M, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016;315:388–406.Google Scholar
Dennis, CL, Falah-Hassani, K, Shiri, R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry 2017;210:315–323.Google Scholar
Hanley, GE, Mintzes, B. Patterns of psychotropic medicine use in pregnancy in the United States from 2006 to 2011 among women with private insurance. BMC Pregnancy Childbirth 2014;14:242.Google Scholar
Riska, BS, Skurtveit, S, Furu, K, et al. Dispensing of benzodiazepines and benzodiazepine-related drugs to pregnant women: a population-based cohort study. Eur J Clin Pharmacol 2014;70:1367–1374.Google Scholar
Haas, M, Qu, Z, Kim, TH, et al. Perturbations in cortical development and neuronal network excitability arising from prenatal exposure to benzodiazepines in mice. Eur J Neurosci 2013;37:1584–1593.Google Scholar
El Marroun, H, White, T, Verhulst, FC, et al. Maternal use of antidepressant or anxiolytic medication during pregnancy and childhood neurodevelopmental outcomes: a systematic review. Eur Child Adolesc Psychiatry 2014;23:973–992.CrossRefGoogle ScholarPubMed
Laegreid, L, Hagberg, G, Lundberg, A. Neurodevelopment in late infancy after prenatal exposure to benzodiazepines – a prospective study. Neuropediatrics 1992;23:60–67.Google Scholar
Lupattelli, A, Chambers, CD, Bandoli, G, et al. Association of maternal use of benzodiazepines and Z-hypnotics during pregnancy with motor and communication skills and attention-deficit/hyperactivity disorder symptoms in preschoolers. JAMA Netw Open 2019;2:e191435.Google Scholar
National Center for Biotechnology Information. PubChem Compound Summary for CID 446220, Cocaine. Available from: https://pubchem.ncbi.nlm.nih.gov/compound/Cocaine [last accessed October 2, 2022].Google Scholar
Cain, MA, Bornick, P, Whiteman, V. The maternal, fetal, and neonatal effects of cocaine exposure in pregnancy. Clin Obstet Gynecol 2013;56:124–132.Google Scholar
Wendell, AD. Overview and epidemiology of substance abuse in pregnancy. Clin Obstet Gynecol 2013;56:91–96.Google Scholar
Oei, JL, Kingsbury, A, Dhawan, A, et al. Amphetamines, the pregnant woman and her children: a review. J Perinatol 2012;32:737–747.Google Scholar
United Nations Office on Drugs and Crime. Amphetamine-type Stimulants. Available from: www.unodc.org/documents/wdr/WDR_2010/2.5_Amphetamine-type_stimulants.pdf [last accessed October 2, 2022].Google Scholar
Keating, E, Gonçalves, P, Campos, I, et al. Folic acid uptake by the human syncytiotrophoblast: interference by pharmacotherapy, drugs of abuse and pathological conditions. Reprod Toxicol 2009;28:511–520.Google Scholar
Tomášková, A, Šlamberová, R, Černá, M. Influence of prenatal methamphetamine abuse on the brain. Epigenomes 2020;4:14. https://doi.org/10.3390/epigenomes4030014Google Scholar
Kain, ZN, Mayes, LC, Ferris, CA, et al. Cocaine-abusing parturients undergoing cesarean section. A cohort study. Anesthesiology 1996;85:1028–1035.Google Scholar
Kuczkowski, KM. Anesthetic implications of drug abuse in pregnancy. J Clin Anesth 2003;15:382–394.Google Scholar
Gupta, AK, Greller, HA, Hoffman, RS. Beta-blockers and cocaine: still a bad idea. Arch Int Med 2010;170:1859–1860; author reply 60.Google Scholar
Goldschmidt, L, Richardson, GA, Cornelius, MD, et al. Prenatal marijuana and alcohol exposure and academic achievement at age 10. Neurotoxicol Teratol 2004;26:521–532.CrossRefGoogle ScholarPubMed
Lester, BM, Tronick, EZ, LaGasse, L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics 2002;110:1182–1192.Google Scholar
Patrick, SW, Schumacher, RE, Benneyworth, BD, et al. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. JAMA 2012;307:1934–1940.Google Scholar
Eyler, EC. Chronic and acute pain and pain management for patients in methadone maintenance treatment. Am J Addict 2013;22:75–83.Google Scholar
Jones, HE, Martin, PR, Heil, SH, et al. Treatment of opioid-dependent pregnant women: clinical and research issues. J Subst Abuse Treat 2008;35:245–259.Google Scholar
Kork, F, Kleinwachter, R, Kaufner, L, et al. [Women in labor who consume substances: significance in obstetric anesthesia.] Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie 2011;46:640–646.Google Scholar
Martin, CE, Terplan, M, Krans, EE. Pain, opioids, and pregnancy: historical context and medical management. Clin Perinatol 2019;46:833–847.Google Scholar
Ordean, A, Kahan, M, Graves, L, et al. Integrated care for pregnant women on methadone maintenance treatment. Can Fam Physician 2013;59:e462–e469.Google Scholar
Park, EM, Meltzer-Brody, S, Suzuki, J. Evaluation and management of opioid dependence in pregnancy. Psychosomatics 2012;53:424–432.Google Scholar
Smith, MV, Costello, D, Yonkers, KA. Clinical correlates of prescription opioid analgesic use in pregnancy. Matern Child Health J 2015;19:548–556.Google Scholar
Towers, CV, Katz, E, Liske, E, et al. Psychosocial background history of pregnant women with opioid use disorder: a prospective cohort study. Am J Perinatol 2020;37:924–928.Google Scholar
Mitra, S, Sinatra, RS. Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology 2004;101:212–227.Google Scholar
Sporer, KA. Acute heroin overdose. Ann Intern Med 1999;130:584–590.Google Scholar
Nelson, L, Schwaner, R. Transdermal fentanyl: pharmacology and toxicology. J Med Toxicol 2009;5:230–241.Google Scholar
Peng, PW, Sandler, AN. A review of the use of fentanyl analgesia in the management of acute pain in adults. Anesthesiology 1999;90:576–599.Google Scholar
Jones, HE, Fischer, G, Heil, SH, et al. Maternal opioid treatment: human experimental research (MOTHER) – approach, issues and lessons learned. Addiction 2012;107(Suppl. 1):28–35.Google Scholar
Souzdalnitski, D, Snegovskikh, D. Analgesia for the parturient with chronic nonmalignant pain. Tech Reg Anesth Pain Manag 2014;18:166–171.Google Scholar
Wiegand, S, Stringer, E, Seashore, C, et al. 750: Buprenorphine/naloxone (B/N) and methadone (M) maintenance during pregnancy: a chart review and comparison of maternal and neonatal outcomes. Am J Obstet Gynecol 2014;210:S368–S369.Google Scholar
Wilder, CM, Winhusen, T. Pharmacological management of opioid use disorder in pregnant women. CNS Drugs 2015;29:625–636.Google Scholar
Brown, HL. Opioid management in pregnancy and postpartum. Obstet Gynecol Clin North Am 2020;47:421–427.Google Scholar
Ecker, J, Abuhamad, A, Hill, W, et al. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol 2019;221:B5–B28.Google Scholar
Faitot, V, Simonpoli, A, Keita, H. Anaesthetic and analgesic considerations in drug abusing pregnant women. Ann Fr Anesth Reanim 2009;28:609–614.Google Scholar
Fultz, JM, Senay, EC. Guidelines for the management of hospitalized narcotic addicts. Ann Int Med 1975;82:815–818.Google Scholar
Goff, M, O’Connor, M. Perinatal care of women maintained on methadone. J Midwifery Womens Health 2007;52:e23–e26.Google Scholar
Gopman, S. Prenatal and postpartum care of women with substance use disorders. Obstet Gynecol Clin North Am 2014;41:213–228.Google Scholar
Harter, K. Opioid use disorder in pregnancy. Ment Health Clin 2019;9:359–372.Google Scholar
Jones, CW, Terplan, M. Pregnancy and naltrexone pharmacotherapy. Obstet Gynecol 2018;132:923–925.Google Scholar
Jones, HE, Finnegan, LP, Kaltenbach, K. Methadone and buprenorphine for the management of opioid dependence in pregnancy. Drugs 2012;72:747–757.Google Scholar
Jones, HE, O’Grady, K, Dahne, J, et al. Management of acute postpartum pain in patients maintained on methadone or buprenorphine during pregnancy. Am J Drug Alcohol Abuse 2009;35:151–156.Google Scholar
Klaman, SL, Isaacs, K, Leopold, A, et al. Treating women who are pregnant and parenting for opioid use disorder and the concurrent care of their infants and children: literature review to support national guidance. J Addict Med 2017;11: 178–190.Google Scholar
Kliman, L. Drug dependence and pregnancy: antenatal and intrapartum problems. Anaesth Intens Care 1990;18:358–360.Google Scholar
Ko, JY, Tong, VT, Haight, SC, et al. Obstetrician-gynecologists’ practice patterns related to opioid use during pregnancy and postpartum – United States, 2017. J Perinatol 2020;40:412–421.Google Scholar
Landau, R. Post-cesarean delivery pain. Management of the opioid-dependent patient before, during and after cesarean delivery. Int J Obstet Anesth 2019;39:105–116.Google Scholar
Ludlow, J, Christmas, T, Paech, MJ, et al. Drug abuse and dependency during pregnancy: anaesthetic issues. Anaesth Intensive Care 2007;35:881–893.Google Scholar
Lugo, RA, Satterfield, KL, Kern, SE. Pharmacokinetics of methadone. J Pain Palliat Care Pharmacother 2005;19:13–24.Google Scholar
Mahoney, K, Reich, W, Urbanek, S. Substance use disorder: prenatal, intrapartum, and postpartum care. MCN Am J Matern Child Nurs 2019;44:284–288.Google Scholar
McNicholas, LF, Holbrook, AM, O’Grady, KE, et al. Effect of hepatitis C virus status on liver enzymes in opioid-dependent pregnant women maintained on opioid-agonist medication. Addiction 2012;107(Suppl. 1):91–97.Google Scholar
Meyer, J, Wagner, K, Benvenuto, A, et al. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy. Obstet Gynecol 2007;110:261–266.Google Scholar
Mozurkewich, EL, Rayburn, WF. Buprenorphine and methadone for opioid addiction during pregnancy. Obstet Gynecol Clin North Am 2014;41:241–253.Google Scholar
Pan, A, Zakowski, M. Peripartum anesthetic management of the opioid-tolerant or buprenorphine/suboxone-dependent patient. Clin Obstet Gynecol 2017;60:447–458.Google Scholar
Pritham, UA, McKay, L. Safe management of chronic pain in pregnancy in an era of opioid misuse and abuse. J Obstet Gynecol Neonatal Nurs 2014;43:554–567.Google Scholar
Raymond, BL, Kook, BT, Richardson, MG. The opioid epidemic and pregnancy: implications for anesthetic care. Curr Opin Anaesthesiol 2018;31:243–250.Google Scholar
Sen, S, Arulkumar, S, Cornett, EM, et al. New pain management options for the surgical patient on methadone and buprenorphine. Curr Pain Headache Rep 2016;20:16.Google Scholar
Soens, MA, He, J, Bateman, BT. Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use. Semin Perinatol 2019;43:149–161.Google Scholar
Tran, TH, Griffin, BL, Stone, RH, et al. Methadone, buprenorphine, and naltrexone for the treatment of opioid use disorder in pregnant women. Pharmacotherapy 2017;37:824–839.Google Scholar
Wendling, AL, Garvan, C, Roussos-Ross, D, et al. Pain outcomes among patients after cesarean consuming buprenorphine or methadone and opioid-naive patients. J Clin Anesth 2020;65:109905.Google Scholar
Wong, S, Ordean, A, Kahan, M ; Society of Obstetricians and Gynecologists of Canada. SOGC clinical practice guidelines: substance use in pregnancy: No. 256, April 2011. Int J Gynaecol Obstet 2011;114:190–202.Google Scholar
Young, JL, Lockhart, EM, Baysinger, CL. Anesthetic and obstetric management of the opioid-dependent parturient. Int Anesthesiol Clin 2014;52:67–85.Google Scholar
Cassidy, B, Cyna, AM. Challenges that opioid-dependent women present to the obstetric anaesthetist. Anaesth Intensive Care 2004;32:494–501.CrossRefGoogle Scholar
Reddi, D, Mehta, A, Patel, N, et al. Perioperative pain management for cesarean section in the mother with severe acute on chronic pain and opioid dependence. Eur J Anaesthesiol 2013;30:178 (abstract).Google Scholar
Vilkins, AL, Bagley, SM, Hahn, KA, et al. Comparison of post-cesarean section opioid analgesic requirements in women with opioid use disorder treated with methadone or buprenorphine. J Addict Med 2017;11:397–401.Google Scholar
Parad, R, McBride, C, Garofalo, F, et al. Equivalent post-cesarean pain and analgesic requirements in women maintained on methadone versus buprenorphine during pregnancy. Am J Obstet Gynecol 2020;222:S309.Google Scholar
Meyer, M, Paranya, G, Keefer Norris, A, et al. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain 2010;14:939–943.Google Scholar
Shainker, SA, Saia, K, Lee-Parritz, A. Opioid addiction in pregnancy. Obstet Gynecol Surv 2012;67:817–825.Google Scholar
Boyle, RK. Intra- and postoperative anaesthetic management of an opioid addict undergoing caesarean section. Anaesth Intensive Care 1991;19:276–279.Google Scholar
Jones, HE, Johnson, RE, Milio, L. Post-cesarean pain management of patients maintained on methadone or buprenorphine. Am J Addict 2006;15:258–259.Google Scholar
Ellis, JD, Cairncross, M, Struble, CA, et al. Correlates of treatment retention and opioid misuse among postpartum women in methadone treatment. J Addict Med 2019;13:153–158.Google Scholar
Vilkins, A, Wachman, EM, Bagley, SM, et al. Comparison of post-cesarean opioid analgesic requirements in methadone- and buprenorphine-maintained women. Obstet Gynecol 2016;127:107S.Google Scholar
Gannon, M, Short, V, Becker, M, et al. Doula engagement and maternal opioid use disorder (OUD): experiences of women in OUD recovery during the perinatal period. Midwifery 2021;106:103243.Google Scholar
Alexander, K, Short, V, Gannon, M, et al. Identified gaps and opportunities in perinatal healthcare delivery for women in treatment for opioid use disorder. Subst Abus 2021;42:552–558.Google Scholar
Peacock-Chambers, E, Paterno, MT, Kiely, D, et al. Engagement in perinatal outpatient services among women in recovery from opioid use disorders. Subst Abus 2021;42:1022–1029.Google Scholar
Gesterling, L, Bradford, H. Cannabis use in pregnancy: a state of the science review. J Midwifery Womens Health 2021 (online). https://doi.org/10.1111/jmwh.13293Google Scholar
Fried, PA. Marijuana use during pregnancy: consequences for the offspring. Semin Perinatol 1991;15:280–287.Google Scholar
Varner, MW, Silver, RM, Rowland Hogue, CJ, et al. Association between stillbirth and illicit drug use and smoking during pregnancy. Obstet Gynecol 2014;123:113–125.Google Scholar
Hernandez, M, Birnbach, DJ, Van Zundert, AA. Anesthetic management of the illicit-substance-using patient. Curr Opin Anaesthesiol 2005;18:315–324.Google Scholar
Das, SK, Paria, BC, Chakraborty, I, et al. Cannabinoid ligand-receptor signaling in the mouse uterus. Proc Natl Acad Sci U S A 1995;92:4332–4336.Google Scholar
Feinshtein, V, Erez, O, Ben-Zvi, Z, et al. Cannabidiol changes P-gp and BCRP expression in trophoblast cell lines. PeerJ 2013;1:e153.Google Scholar
Feinshtein, V, Erez, O, Ben-Zvi, Z, et al. Cannabidiol enhances xenobiotic permeability through the human placental barrier by direct inhibition of breast cancer resistance protein: an ex vivo study. Am J Obstet Gynecol 2013;209:573.e1–e15.Google Scholar
Houlihan, DD, Dennedy, MC, Morrison, JJ. Effects of abnormal cannabidiol on oxytocin-induced myometrial contractility. Reproduction 2010;139:783–788.Google Scholar
Davidson, EM, Raz, N, Eyal, AM. Anesthetic considerations in medical cannabis patients. Curr Opin Anaesthesiol 2020;33:832–840.Google Scholar
Figurasin, R, Maguire, NJ. 3,4-Methylenedioxy-Methamphetamine Toxicity. [Updated July 26, 2021]. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2022. Available from: www.ncbi.nlm.nih.gov/books/NBK538482 [last accessed October 2, 2022].Google Scholar
Holmes, LB. Letter: ocular malformations associated with maternal LSD usage. Arch Ophthalmol 1975;93:1061.Google Scholar
Aase, JM, Laestadius, N, Smith, DW. Children of mothers who took LSD in pregnancy. Lancet 1970;1(7663):100–101.Google Scholar
Chan, CC, Fishman, M, Egbert, PR. Multiple ocular anomalies associated with maternal LSD ingestion. Archi Ophthalmol 1978;96:282–284.Google Scholar
Strauss, AA, Modaniou, HD, Bosu, SK. Neonatal manifestations of maternal phencyclidine (PCP) abuse. Pediatrics 1981;68:550–552.Google Scholar
Eze, N, Smith, LM, LaGasse, LL, et al. School-aged outcomes following prenatal methamphetamine exposure: 7.5-year follow-up from the infant development, environment, and lifestyle study. J Pediatr 2016;170:34–38.e1.Google Scholar
Gorman, MC, Orme, KS, Nguyen, NT, et al. Outcomes in pregnancies complicated by methamphetamine use. Am J Obstet Gynecol 2014;211:429.e1–e7.Google Scholar
Wouldes, T, LaGasse, L, Sheridan, J, et al. Maternal methamphetamine use during pregnancy and child outcome: what do we know? N Z Med J 2004;117:U1180.Google Scholar
Fischer, SP, Healzer, JM, Brook, MW, et al. General anesthesia in a patient on long-term amphetamine therapy: is there cause for concern? Anesth Analg 2000;91:758–759.Google Scholar
Johnston, RR, Way, WL, Miller, RD. Alteration of anesthetic requirement by amphetamine. Anesthesiology 1972;36:357–363.Google Scholar
Demick, DS, Lee, TT, Summers, AT, et al. Kratom: a growing substance of abuse in the United States. Ann Clin Psychiatry 2020;32:275–280.Google Scholar
U.S. Food and Drug Administration. FDA and Kratom. Available from: www.fda.gov/news-events/public-health-focus/fda-and-kratom [last accessed October 2, 2022].Google Scholar
Vermaire, DJ, Skaer, D, Tippets, W. Kratom and general anesthesia: a case report and review of the literature. A&A Practice 2019;12:103–105.Google Scholar
Smid, MC, Charles, JE, Gordon, AJ, et al. Use of Kratom, an opioid-like traditional herb, in pregnancy. Obstet Gynecol 2018;132:926–928.Google Scholar
Mackay, L, Abrahams, R. Novel case of maternal and neonatal kratom dependence and withdrawal. Can Fam Physician 2018;64:121–122.Google Scholar
National Institute on Drug Abuse (NIDA). Substance abuse while pregnant and breastfeeding. Available from: www.drugabuse.gov/publications/research-reports/substance-use-in-women/substance-use-while-pregnant-breastfeeding [last accessed October 2, 2022].Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×