Alcohol Use in Pregnancy

1. Alcohol Use in Pregnancy Melanie McKean, D.O., Ph.D. Department of Neurology and Psychiatry Saint Louis University

2. http://clutchmag.s3.amazonaws.com/wp-content/uploads/2012/06/Alcohol-in-pregnancy-copy-533x800.jpeghttp://clutchmag.s3.amazonaws.com/wp-content/uploads/2012/06/Alcohol-in-pregnancy-copy-533x800.jpeg © Alcohol Medical Scholars Program

3. Introduction Alcohol: ↑ pregnancy risks ↑ risks to fetus Birth defects are preventable © Alcohol Medical Scholars Program

4. Alcohol Use & Pregnancy • Definitions • Risk factors • Drinking effects in pregnancy • Prevention and treatment © Alcohol Medical Scholars Program

5. 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 © Alcohol Medical Scholars Program

6. DEFINITIONS © Alcohol Medical Scholars Program

7. What is a Standard Drink? http://www.niaaa.nih.gov/sites/default/files/just_drinks_for_web.jpg © Alcohol Medical Scholars Program

8. Definitions • Heavy episodic drinking • Alcohol dependence • Alcohol abuse • Alcohol use disorder (DSM-V) © Alcohol Medical Scholars Program

9. Heavy Episodic Drinking • 4+ std drinks/event♀ • 5+ std drinks/event ♂ • 7+ drinks/week♀ © Alcohol Medical Scholars Program

10. 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 Medical Scholars Program

11. Alcohol Abuse • 1+ same 12 mos (if not dependent) of: • Role failure • Placing self hazardous situations • Legal problems • Social/interpersonal problems © Alcohol Medical Scholars Program

12. Alcohol Use Disorder • DSM-V (2013) • Single list of 11 items • Moderate: 2 or 3 criteria + • Severe: ≥ 4 criteria + © Alcohol Medical Scholars Program

13. RISK FACTORS http://www.eumom.ie/blog/wp-content/uploads/2011/08/babyalcohol.jpg © Alcohol Medical Scholars Program

14. 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 © Alcohol Medical Scholars Program

15. Who Drinks while Pregnant? • Pre-pregnancy drinker • Unmarried • Comorbid psych and med dx • Age ≥ 35 • Less education © Alcohol Medical Scholars Program

16. What about Our Cases? Case 1 Case 2 No Alcohol Use Disorder Alcohol Dependence © Alcohol Medical Scholars Program

17. DRINKINGEFFECTSINPREGNANCY © Alcohol Medical Scholars Program

18. 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 © Alcohol Medical Scholars Program

19. Fetal Alcohol Spectrum Disorders (FASD) © Alcohol Medical Scholars Program

20. Fetal Alcohol Syndrome • 1980 • Neuro, behavioral, cognitive deficits • Poor growth, learning, socialization • 4 major criteria: • Characteristic facial abnormalities • Brain structural, neuro, functional defic • Growth deficiencies • Maternal alcohol use during pregnancy © Alcohol Medical Scholars Program

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22. 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 Medical Scholars Program

23. 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 Medical Scholars Program

24. 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

25. 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 © Alcohol Medical Scholars Program

26. Neonatal Risk Factors • Inadequate prenatal care • Social isolation • ↑ Stress © Alcohol Medical Scholars Program

27. Lactation • ACOG Committee opinion • Breastfeeding after drinking: • ↓ milk intake • ↓ sleep & postnatal growth • Don’t breastfeed for 3 hrs after ETOH © Alcohol Medical Scholars Program

28. PREVENTION& TREATMENT http://pernod-ricard.com/files/contenu/4.4.4-Les-femmes-enceintes_small_0.jpg © Alcohol Medical Scholars Program

29. Prevention • ABSTINENCE IS SAFEST • Surgeon General statement • Surgeon General recs © Alcohol Medical Scholars Program

30. 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 © Alcohol Medical Scholars Program

31. Brief Intervention • Elements • FACT • Feedback problem to patient • Advice re stop drinking • Commitment to keep monitoring • Tracking patient’s outcome http://www.sciencemediacentre.co.nz/wp-content/upload/2012/06/PregAlcohol1.jpg © Alcohol Medical Scholars Program

32. 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 © Alcohol Medical Scholars Program

33. 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 © Alcohol Medical Scholars Program

34. Treatment • Four goals: • Build motivation for abstinence • Enhance life functioning • Restructure life w/o substances • Prevent relapse • Immediate action necessary • Inpatient detox tx as needed • Collaborative approach © Alcohol Medical Scholars Program

35. 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 © Alcohol Medical Scholars Program

36. 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

37. 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 © Alcohol Medical Scholars Program

38. Summary • Alcohol + pregnancy = Concern • Alcohol + pregnancy = Risk • Abstinence is safest • Screening essential • Collaborative care key © Alcohol Medical Scholars Program

39. 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 Medical Scholars Program

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