alcohol use in pregnancy melanie mckean, d.o., ph.d. department of neurology and psychiatry saint...

Alcohol Use in Pregnancy

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

Department of Neurology and Psychiatry

Saint Louis University

© Alcohol Medical Scholars Program 2

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Introduction

Alcohol: ↑ pregnancy risks

↑ risks to fetus

Birth defects are preventable

Alcohol Use & Pregnancy

1. Definitions

2. Risk factors

3. Drinking effects in pregnancy

4. Prevention and treatment


Cases

• Case 1

– 27yo WF, 1st pregnancy

– Recognition 10 wks

– H/O depression

– Pattern:

• 2-5+ drinks/night

• Blackouts

• ↑ Drinks for same effect

• DUI 2 yrs ago

• No alcohol since knew pregnant

• Case 2

– 36 yo AAF, 2nd preg

– Recognition 4 wks

– No psych hx

– Pattern:

• 1 wine/night

• 1 glass/week w preg


DEFINITIONS



What is a Standard Drink?

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Definitions

• Heavy episodic drinking

• Alcohol dependence

• Alcohol abuse

• Alcohol use disorder (DSM-V)

Heavy Episodic Drinking

•4+ std drinks/event♀

•5+ std drinks/event ♂

•7+ drinks/week♀


Alcohol Dependence

• 3+ same 12 months of:– Tolerance– Withdrawal– Intake > or longer than intended– Unsuccessful cutting down/controlling use– ↑ time spent obtaining substance– ↓ social/occupational/recreational activities– Continued use despite physical/psych problem


Alcohol Abuse

• 1+ same 12 mos (if not dependent) of:

–Role failure

–Placing self hazardous situations

–Legal problems

–Social/interpersonal problems


Alcohol Use Disorder

• DSM-V (2013)

• Single list of 11 items

• Moderate: 2 or 3 criteria +

• Severe: ≥ 4 criteria +


RISK FACTORS

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Alcohol Use in Pregnancy

• Prevalence in ♀ who know pregnant

– 2%: ≥ 5 drinks/occasion 5+ days past mo

– 28% ≥ 5 drinks typical drinking days

– 21% 45 drinks per month

• ~50% pregnancies unplanned

– 50% don’t know pregnant early

– 45% drink before know pregnant

– ~5% ♀ drink ≥ 6 drinks/ week


Who Drinks while Pregnant?

• Pre-pregnancy drinker

• Unmarried

• Comorbid psych and med dx

• Age ≥ 35

• Less education


What about Our Cases?

Case 1

Alcohol

Dependence

Case 2

No

Alcohol

Use

Disorder


DRINKINGEFFECTS

INPREGNANCY


Fetal Alcohol Effects - History

• 1600s: Sir Francis Bacon

• 1700s: UK gov’t, gin tax

• 1800s: Appearance of ETOH mothers’ infants


• 1900s: Fetal alcohol effects identified

– Lemoine – “Alcohol embryopathy”

– Jones & Smith – malformations, ↓growth, CNS defects

– FAS prevention programs

– Surgeon General warning

– Alcohol Beverage Labeling Act

Fetal Alcohol Spectrum Disorders (FASD)


Fetal Alcohol Syndrome

• 1980

• Neuro, behavioral, cognitive deficits

• Poor growth, learning, socialization

• 4 major criteria:1. Characteristic facial abnormalities

2. Brain structural, neuro, functional defic

3. Growth deficiencies

4. Maternal alcohol use during pregnancy


Partial FAS

• Confirmed ETOH exposure in utero

• 2+ characteristic minor facial anomalies

• 1+ of:

– Growth retardation

– Deficient brain growth

– Behavioral/cognitive abnormalities

• How pFAS differs from FAS


Alcohol-Related Neurodevelopmental Disorder

• 3+ CNS impairments

• Few or no facial abnormalities

• Growth deficiency

• Prenatal alcohol exposure

• Differs from other FASD by:

– Focus on CNS deficits

– Minimal to no growth or facial abnormalities


Alcohol-Related Birth Defects

• Not fit other FASD category

• Maternal ETOH exposure

• Minor facial anomalies

• 1+ Congenital defects:– Cardiac

– Renal

– Skeletal

– Eye, ear© Alcohol Medical Scholars Program 24

Maternal Risk Factors for FASD

• ↑ Quantity & frequency of drinking

• Drank 1st trimester

• Poor health and nutrition

• Live where heavy drinking common

• Little awareness of FASD


Neonatal Risk Factors

• Inadequate prenatal care

• Social isolation

• ↑ Stress


Lactation

• ACOG Committee opinion

• Breastfeeding after drinking:– ↓ milk intake

– ↓ sleep & postnatal growth

• Don’t breastfeed for 3 hrs after ETOH


PREVENTION&

TREATMENT


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Prevention

• ABSTINENCE IS SAFEST

• Surgeon General statement

• Surgeon General recs


Screening/Intervention

• OB/GYNs intervene re: at-risk ETOH

– ID ♀ heavy episodic drinking bf pregnant

– Screen for drinking while pregnant

– Brief intervention & education

– Non-pregnant pt goals

– Pregnant pt goals = abstinence

• Refer pts w/ Alcohol Dependence for Tx


Brief Intervention

•Elements

•FACT–Feedback problem to patient–Advice re stop drinking–Commitment to keep monitoring –Tracking patient’s outcome


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Brief Interventions with Cases

• Case 1

– Discussed hx of alcohol dependence

– Advised cont’d abstinence

– Encouraged commitment

– Frequent appts to monitor

• Case 2

– Informed pt of risk of ETOH during pregnancy

– Advised to stop drinking

– Encouraged commitment

– Frequent appts for tracking


Screening Tools for OB/GYNs

• TACE– Tolerance, annoyed, cut down, eye opener

– ≥ 2 pts = at-risk drinking

• AUDIT– Accurate across all genders, ethnic groups

– 10 multiple choice questions

– Score > 8 indicates ETOH problem


Treatment

• Four goals:

1. Build motivation for abstinence

2. Enhance life functioning

3. Restructure life w/o substances

4. Prevent relapse

• Immediate action necessary

• Inpatient detox tx as needed

• Collaborative approach


Intensive Outpatient Treatment

• Motivational enhancement

• Assess high-risk situations

• Collaboratively plan to manage risks

• Close monitoring to prevent relapse

• Regular supportive counseling

• Tailor med/psych assessment to needs

• Educate on benefits of abstinence


Case 1

• OB/GYN used BI

• Referred to psych for depression

• Pt abstinent thru pregnancy

• Baby born with:– short palpebral fissures– smooth philtrum– prenatal growth retardation– structural brain abnormalities

• c/w pFAS© Alcohol Medical Scholars Program 36

Case 2

• OB/GYN used BI

• Referred to psychiatry, did not go

• Attended all prenatal appointments

• Reported abstinence from alcohol

• Baby born without signs of FASD



Summary

• Alcohol + pregnancy = Concern

• Alcohol + pregnancy = Risk

• Abstinence is safest

• Screening essential

• Collaborative care key

Resources

• Alcohol’s Effects on the Body: http://www.niaaa.nih.gov/alcohol-health/alcohols-effects-body

• Alcohol’s Effects on the Fetus: http://www.niaaa.nih.gov/alcohol-health/fetal-alcohol-exposure

• National Organization on Fetal Alcohol Syndrome: http://www.nofas.org/


alcohol use in pregnancy melanie mckean, d.o., ph.d. department of neurology and psychiatry saint...

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