Alcohol Use during Pregnancy

Melanie McKean, D.O., Ph.D.

Saint Louis University

Alcohol Medical Scholars Program, Junior Scholar, 2012-2013

(Slide 1)

 

I.       Introduction

A.    Graphic of pregnant woman drinking wine – comment on shock value (Slide 2)

B.     Alc risks regarding pregnancy1 (Slide 3)

1.      Violence from drinking partner

2.      Accidents

3.      Unwanted pregnancy

C.     Also risks to fetus

1.      Miscarriage

2.      Birth defects

3.      Developmental disabilities

D.    Alcohol during pregnancy: leading preventable cause of birth defects and disabilities2

E.     This lecture covers (Slide 4)

1.      Definitions regarding drinking in pregnancy

2.      Risk factors for and patterns of alcohol use in pregnancy

3.      Drinking effects in pregnancy (fetal alcohol effects)

4.      Prevention and treatment

F.      Lecture presents 2 cases: Case 1 (Slide 5)

1.      27-year-old WF, pregnant with 1st child

2.      Pregnancy unplanned, but welcomed

3.      Knew of pregnancy at ~10 weeks

4.      Happily married, supportive spouse

5.      No medical problems

6.      H/O depressive episode ~age 24 – not currently depressed, nor on treatment

7.      Alcohol pattern prior to pregnancy recognition:

a.       2-3 glasses of wine nightly

b.      Every other weekend, drinks ≥ 5 drinks /day with friends

c.       Frequent blackouts

d.      Increased # drinks to get same effect

e.       H/O DUI 2 years ago; did not deter drinking habits 

8.      No alcohol intake since pregnancy recognition

G.    Case 2

1.      36 yo AAF, pregnant with 2nd child

2.      Planned pregnancy

3.      Recognition of pregnancy at time of missed menses (~4 weeks)

4.      1st pregnancy drank 1st 3 mo post recognition (~ 1 glass with dinner)

5.      1st child healthy

6.      In committed relationship, supportive partner

7.      No medical or psychiatric comorbidities

8.      Alcohol pattern prior to pregnancy recognition: glass of wine nightly with dinner

9.      Has had a glass of wine once per week since pregnancy recognition

10.  Denies any alcohol problems       

II.    Definitions (Slide 6)

A.    A standard drink (10-12 grams pure ethanol): (Slide 7)

1.      12 oz beer

2.      8 oz malt liquor

3.      4 oz wine

4.      1.5 oz 80 proof liquor

B.     Definitions (Slide 8)

1.      Heavy episodic drinking

2.      Alcohol dependence

3.      Alcohol abuse

4.      Alcohol use disorder (DSM-V)

C.     Heavy episodic drinking (“binge”) (Slide 9)

1.      4+ std drinks/event for

2.      5+ std drinks/event for  

3.      7+ drinks/week in ♀ = unhealthy drinking

D.    Any alcohol intake when pregnant = problem drinking

1.      ETOH use vs other abused substances, ETOH-> most serious neurobehavioral effects

E.     Alcohol use disorder criteria

1.      Alcohol dependence - 3+ in same 12 months of: 3 (Slide 10)

a.       Tolerance

b.      Withdrawal

c.       Intake more or for longer periods than intended

d.      Unsuccessful cutting down/controlling use

e.       time spent obtaining substance

f.       social/occupational/recreational activities

g.      Continued use despite physical/psychological problem

2.      Alcohol abuse - 1+ in same 12 months if not dependent of: 3 (Slide 11)

a.       Role failure

b.      Placing self in physically hazardous situations

c.       Legal problems

d.      Social/interpersonal problems

3.      In DSM-V (2013) single list of 11 items = Alcohol Use Disorder 4 (Slide 12)

III.  Risk Factors for alcohol use in pregnancy (Slide 13)

A.    Alcohol use in pregnancy (Slide 14)

1.      Prevalence in who know are pregnant 5

a.       2% pregnant:   5 drinks/occasion 5+days past mo

b.      28% ≥ 5 drinks typical drinking days

c.       ~21% of ³45 drinks per month

2.      But ~ 50% pregnancies are unplanned 6

a.       50% don’t know if pregnant early when fetus most vulnerable

b.      45 % ♀ drink some alcohol before know pregnant

c.       ~5% ♀ drink ≥ 6 drinks/ week (before know pregnant)

B.     Drinking when pregnant higher in subgroups: 2,7,8  (Slide 15)

1.      Used alcohol before pregnancy

2.      Unmarried

3.      Have psychiatric dx (major depressive dx, bipolar, schizophrenia)

4.      Have med dx (e.g., diabetes or blood pressure)

5.      Age ≥35

6.      Less education

C.     Review the 2 cases: (Slide 16)

1.      Case 1 drinking patterns

a.       Pre-pregnancy recognition

b.      2-3 glasses wine nightly, 4 sat/sun per mo has ≥ 5 drinks/day

c.       Since pregnancy recognition: no drinking

d.      Alcohol Dependence

2.      Case 2 drinking patterns

a.       Pre-pregnancy recognition: glass of wine nightly

b.      Since know pregnant: 1 glass of wine per week

c.       No Alcohol Use Disorder

IV.  Drinking effects in pregnancy (Slide 17)

A.    Fetal effects - history 9 (Slide 18)

1.      1600s: Sir Francis Bacon warned to not drink if pregnant

2.      1700s:U.K. government took steps to reverse gin effect on birth defects

a.       Gin tax had been so, price

b.      Drinking ; so did infant deaths

3.      1800s:

a.       U.K. report: Infants of alcoholic mothers look starved & imperfect 

b.      French doc: mom drink kid small heads, odd face, & nervous

4.      1900s–fetal alcohol effects identified

a.       At first not sure if cause alcohol, genes, or nutrition 

b.      1968 - Lemoine ID’d “alcoholic embryopathy”

c.       1973 - Jones and Smith ID’d malformations, growth , CNS defects

d.      FAS prevention programs began in late 1970s

e.       Surgeon General warned about alcohol use in 1981

f.       Congress passed Alcoholic Beverage Labeling (warning) Act in 1988

B.     Fetal alcohol spectrum disorders (FASD) – umbrella term 9,10,11 (Slide 19)

1.      Includes Fetal Alcohol Syndrome (FAS) (Slide 20)

a.       First recognized ~ 1980 12

b.      Pattern of neurologic, behavioral, cognitive deficits 9,10,11

c.       Interferes w/ growth, learning, socialization

d.      4 major criteria:

1'.     Characteristic facial abnormalities (Slide 21)

a'.     Epicanthal (eye corner) folds

b'.     Ptosis (droopy eyelids)

c'.     Low nasal bridge

d'.    Flat midface & philtrum (vertical crease under nose)

e'.     Minor ear anomalies (e.g., low set ears)

f'.      Short nose

g'.     Micrognathia (small jaw)

2'.     Brain structural, neurological, functional deficits in:

a'.     Frontal lobes ( impulsivity, judgment)

b'.     Cerebellum ( coordination)

c'.     Basal ganglia ( memory problems)

3'.     Growth deficiencies

4'.     Maternal alcohol use during pregnancy

e.       FAS impacts on development

1'.     Mental retardation

2'.     Problems focusing attention for long

3'.     Hyperactivity

4'.     Poor impulse control

5'.     Problems in reading social cues

a'.     Verbal/nonverbal hints guiding conversation

b'.     Facial expressions, vocal tone, posture, proximity, etc

c'.     Misinterpretation may lead to negative social interactions

6'.     Speech and language delays/deficits

7'.     Poor capacity for abstract thinking

8'.     Math skills deficits

9'.     Memory and judgment problems

10'. Problems changing behavior/response in situations

2.      FASD also includes Partial Fetal Alcohol Syndrome (pFAS) 9,10,11 (Slide 22)

a.       Confirmed alcohol exposure in utero

b.      2+ characteristic minor facial anomalies of FAS

1'.     Short palpebral fissures (eye slits)

2'.     Thin vermillion border of upper lip

3'.     Smooth philtrum           

c.       1 + of:

1'.     Growth retardation (prenatal and/or postnatal)

2'.     Deficient brain growth/abnormal morphogenesis

a'.     Structural brain abnormalities

b'.     Head circumference 10th percentile

3'.     Behavioral or cognitive abnormalities

a'.     Marked impairment complex tasks (problem solving, planning, etc)

b'.     Have emotions (lability), social interactions

d.      Differs from FAS

1'.      “Look” less severe (less growth retardation, facial features)

2'.     CNS impairment essentially the same

3.      FASD includes Alcohol-Related Neurodevelopmental Disorder (ARND) 9,10,11 (Slide 23)

a.       3+ CNS structural, neurological, or functional impairments

b.      Few or no facial abnormalities

c.       Growth deficiency

d.      Prenatal alcohol exposure

e.       Differs from other FASD by:

  1’. Focus on CNS deficits

                    2’. Minimal to no growth or facial abnormalities

4.      FASD also includes Alcohol-Related Birth Defects (ARBD) 9,10,11 (Slide 24)

a.       Not fit any other FASD category

b.      Confirmed maternal alcohol exposure

c.       Minor facial anomalies

d.      Congenital structural defects, in 1+ of:

1'.     Cardiac: septal defects, abnormal great vessels

2'.     Renal: kidney shape and size abnormalities

3'.     Skeletal: scoliosis (curvature), large joint contractures (fused elbow)

4'.     Eye: lid droop, blood vessel or nerve anomalies in the eye

5'.     Ear: hearing loss

6'.     Minors: short 5th digits, abnormal bent of fingers, chest deformities (pidgeon)

C.     Risk factors for FASD among drinkers 13 (Slide 25)

1.      Higher quantity & frequency alcohol (minimum limits unknown)

2.      Drinking in first 3 months pregnancy

3.      Maternal poor health & inadequate nutrition

4.      Living where heavy drinking common and/accepted (e.g., S. Africa vineyards)

5.      Little awareness of FASD

D.    Neonatal risk factors that severity of FASD (Slide 26)

1.      Inadequate prenatal care

2.      Social isolation

3.      Stress

E.     Maternal drink also affects lactation 14 (Slide 27)

1.      breast milk intake by infants

2.      Can sleep & postnatal growth

3.      So: not to breastfeed within 3 hours of drink

 

V.    Prevention, screening, & treatment of alcohol use in pregnancy (Slide 28)

A.    Prevention (Slide 29)

1.      Primary message: ABSTINENCE IS SAFEST

a.       Surgeon General statement based on (originally 1981, reiterated 2005): 12

1'.     Alcohol during pregnancy risk alcohol related birth defects

2'.     No amount of alcohol is safe

3'.     Alcohol can damage fetus at any stage of pregnancy

4'.     Resulting cognitive/behavioral problems lifelong

5'.     Birth defects related to alcohol are preventable

b.      Surgeon General recommends: 12

1'.     Pregnant should not drink

2'.     If drinking, should stop

3'.     If considering pregnancy, should stop alcohol

4'.     should seek medical care to prenatal alcohol exposure

5'.     Repeated screens needed in of child-bearing age

6'.     Healthcare provider training/screening strategies

B.     Screening/Intervention (Slide 30)

1.      Ob/Gyns should ID/intervene at-risk alcohol use 14

a.       Identify with heavy episodic drinking before pregnant

b.      Screen for any drinking when pregnant

c.       If problem, use brief intervention (BI) & education

d.      Non-pregnant pts: goal to moderate drinking to ≤ “at risk drinking” level

e.       Pregnant pts: goal = abstinence

f.       Refer patients w/ alcohol dependence for Rx

2.      Brief Intervention 15,16 (Slide 31)

a.       Often done by primary care physicians

b.      BI often used in non-alcohol dependent pts

c.       Generally 4 or fewer sessions

d.      Session as short as 10 minutes

e.       Element of BI (FACT) 15

1'.     Feedback problem to patient
2'.     Advice re stop drinking
3'.     Commitment to keep monitoring
4'.     Tracking patient’s outcome

f.       BI with Case 1 (Slide 32)

1'.     Discussed history of alcohol dependence

2'.     Advised to continue abstinence during pregnancy

3'.     Encouraged commitment

4'.     Doc monitors with frequent appts

g.      BI with Case 2

1'.     Informed pt of risk of ongoing drinking during pregnancy

2'.     Advised to stop drinking

3'.     Encouraged commitment

4'.     Frequent appts for tracking

3.      Screening tools for OB/GYNs (Slide 33)

a.       Needed as > deny alcohol problems 14

1'.     Fear of loss of children, relationships

2'.     When seek help – often from primary care or OB doc

b.      TACE Questionnaire preferred for 14

1'.     T – Tolerance (# drinks it takes to feel high? >2 drinks = 2 pts)

2'.     A – Annoyed (Is annoyed if drinking criticized?             Yes = 1 pt)

3'.     C – Cut down (Felt needed cut down on drinking? Yes = 1 pt)

4'.     E – Eye-opener (Drank in a.m. to steady nerves or hang? Yes = 1 pt)

5'.     2 pts or more indicates at-risk drinking

6'.     Additional questions may be added re: quantity & frequency of use

a'.     In typical week, # alcoholic drinks?
b'.     # days last 3 months had > 3 drinks on any occasion?

c.       AUDIT is also good 17

1'.     Developed by WHO in 1982

2'.     Accurate across all gender and ethnic groups

3'.     Ten multiple choice questions

a'.     Quantity and frequency of alcohol consumption

b'.     Drinking behavior

c'.     Alcohol-related problems or reactions

4'.     ’Score > 8 indicates  alcohol problem

5'.     Our patients’ scores

a'.     Case 1: TACE 4, Audit Total Score 19, Dependent

b'.     Case 2: TACE 1; Audit Total Score 4, Not dependent

C.     Treatment (Slide 34)

1.      Four goals: 18

a.       Build motivation for abstinence

b.      Enhance life functioning

c.       Restructure life without substances

d.      Prevent relapse

2.      Due to risk to unborn child, immediate action essential

3.      Inpatient detoxification treatment (if needed)

a.       Enables goal of abstinence to be achieved safely and quickly

b.      Cautious use of benzodiazepines

4.      Collaborative approach between OB/GYN and treatment programs

5.      Intensive outpatient rehabilitation (Slide 35)

a.       Motivational enhancement

1'.     Keep patient engaged and attending treatment

2'.     For pregnant , discuss risk of losing newborns

3'.     Small goals reinforced (abstinence, mtg attendance)

4'.     Trustful relationship with Rx staff crucial

b.      Assess high-risk situations for drinking

c.       Work with patient to develop plans to manage high-risk situations

d.      Close monitor to prevent relapses

1'.     Provide encouragement

2'.     Intervene quickly

e.       Regular supportive counseling

f.       Tailor medical & psychosocial assessment to pt’s needs

1'.     Benefit/risk assessment regarding meds

2'.     Consider finances of pt to enhance adherence

g.      Educate why total abstinence crucial to deliver healthy child

6.      Steps taken for cases

a.       Case 1 (Slide 36)

1'.     OB/GYN employed BI strategies

2'.     Referred to psychiatrist for depression assessment

3'.     Pt remained abstinent from alcohol throughout pregnancy

4'.     Baby born with short palpebral fissures, smooth philtrum, prenatal growth retardation, including structural brain abnormalities (signs/symptoms c/w pFAS)

b.      Case 2 treatment strategies and outcome (Slide 37)

1'.     OB/GYN employed BI strategies

2'.     Referred pt to psychiatry as well—pt did not attend appt

3'.     Pt did attend all prenatal appointments and reported abstinence from alcohol

4'.     Baby born without signs or symptoms of FASD

 

VI. Summary (Slide 38)

A.    Alcohol use during pregnancy is important public health concer

B.     Any alcohol use during prengnayc is risky

C.     Zero exposure = zero risk for FASD

D.    Screening essential (and should be done repeatedly)

E.     Collaborative care is key

F.      Website referrals (Slide 39)

G.    Graphic during questions (Slide 40)

               

References

 

1.                  Centers for Disease Control and Prevention.  Alcohol and Public Health Fact Sheets: Excessive Alcohol Use and Risk to Women’s Health.  http://www.cdc.gov/alcohol/fact-sheets/womens-health.htm. Accessed December 2012.

2.                  Alcohol Use and Binge Drinking Among Women of Childbearing Age—United States, 2006-2010. MMWR. July 20, 2012; 61(28): 534-538.

3.                  American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev). Washington, DC: Author.

4.                  NAMI Comments on the APA’s Draft Revision of the DSM-V – Substance Use Disorders.  http://www.nami.org/Content/ContentGroups/Policy/Issues_Spotlights/DSM5/Substance_Use_Disorder_Paper_4_13_2010.pdf. Accessed March 2013.

5.                  Tsai J, Floyd RL, Green PP, Boyle CA. Patterns and average volume of alcohol use among women of childbearing age. Matern Child Health J 2007; 11: 437-445.

6.                  Floyd RL, Decoufle P, Hungerford SW.  Alcohol use prior to pregnancy recognition. Am J Prev Med 1999; 17(2): 101-107.

7.                  Naimi, TS, Lipscomb, LE, Brewer, RD, and Gilbert, BC.  Binge drinking in the preconception period and the risk of unintended pregnancy: implications for women and their children.  Pediatrics 2003; 111: 1136-1141.

8.                  Skagerstrom, J. Predictors of drinking during pregnancy: a systematic review. J Women’s Health 2011; 20(6): 901-913.

9.                  Fetal Alcohol Spectrum Disorders, Center for Excellence.  Curriculum for Addiction Professionals (CAP).

10.              National Organization on Fetal Alcohol Syndrome. http://www.nofas.org/ . Accessed December 2012.

11.              Sanford School of Medicine of The University of South Dakota. Fetal Alcohol Spectrums Disorder Handbook.  Sioux Falls, SD: Author.

12.              Advisory on Alcohol Use During Pregnancy.  A 2005 Message to Women from the U.S. Surgeon General.  Centers for Disease Control and Prevention: National Center on Birth Defects and Developmental Disabilities.

13.              Fetal Alcohol Exposure.  National Institute on Alcohol Abuse and Alcoholism website.  http://www.niaaa.nih.gov/alcohol-health/fetal-alcohol-exposure. Accessed December 2012.

14.              At-Risk Drinking and Alcohol Dependence: Obstetric and Gynecologic Implications. The American College of Obstetricians and Gynecologists: Committee Opinion. Obstetrics and Gynecology.  August 2011; 118 (2): 383-388.

15.              Bierut LJ. Screening and brief interventions for heavy drinking.  Alcohol Medical Scholars Program presentation. July 2000.

16.              Brief Intervention for Drinking Problems in Medical Settings. Adapted from NIAAA. http://www2.potsdam.edu/hansondj/HealthIssues/1079981573.html. Accessed March 2013.

17.              Bohn MJ, Babor TF, Kranzler HR. The Alcohol Use Disorders Identification Test (AUDIT): validation of a screening instrument for use in medical settings. J Stud Alcohol. 1995 Jul; 56(4): 423-32.

18.              Metz V, Kochl B, Fischer. Should pregnant women with substance use disorders be managed differently?  Neuropsychiatry. 2012; 2(1): 29-41.