Alcohol Use in Pregnancy Melanie Mc Kean D

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

http: //clutchmag. s 3. amazonaws. com/wp-content/uploads/2012/06/Alcohol-in-pregnancy-copy-533 x 800. jpeg © Alcohol Medical Scholars Program 2

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

Alcohol Use & Pregnancy 1. Definitions 2. Risk factors 3. Drinking effects in pregnancy 4. Prevention and treatment © Alcohol Medical Scholars Program 4

Cases • Case 1 • Case 2 – 27 yo WF, 1 st pregnancy – 36 yo AAF, 2 nd preg – Recognition 10 wks – Recognition 4 wks – H/O depression – No psych hx – Pattern: • 2 -5+ drinks/night • 1 wine/night • Blackouts • 1 glass/week w preg • ↑ Drinks for same effect • DUI 2 yrs ago • No alcohol since knew pregnant © Alcohol Medical Scholars Program 5

DEFINITIONS © Alcohol Medical Scholars Program 6

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

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

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

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 10

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 11

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

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

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 14

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

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

DRINKING EFFECTS IN PREGNANCY © Alcohol Medical Scholars Program 17

Fetal Alcohol Effects - History • 1600 s: Sir Francis Bacon • 1700 s: UK gov’t, gin tax • 1800 s: Appearance of ETOH mothers’ infants • 1900 s: 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 18

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

Fetal Alcohol Syndrome • • 1980 Neuro, behavioral, cognitive deficits Poor growth, learning, socialization 4 major criteria: 1. 2. 3. 4. Characteristic facial abnormalities Brain structural, neuro, functional defic Growth deficiencies Maternal alcohol use during pregnancy © Alcohol Medical Scholars Program 20

© Alcohol Medical Scholars Program 21

Partial FAS • Confirmed ETOH exposure in utero • 2+ characteristic minor facial anomalies • 1+ of: – Growth retardation – Deficient brain growth – Behavioral/cognitive abnormalities • How p. FAS differs from FAS © Alcohol Medical Scholars Program 22

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 23

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 1 st trimester • Poor health and nutrition • Live where heavy drinking common • Little awareness of FASD © Alcohol Medical Scholars Program 25

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

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

PREVENTION & TREATMENT http: //pernod-ricard. com/files/contenu/4. 4. 4 -Les-femmes-enceintes_small_0. jpg © Alcohol Medical Scholars Program 28

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

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 30

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/Preg. Alcohol 1. jpg © Alcohol Medical Scholars Program 31

Brief Interventions with Cases • Case 1 • Case 2 – Discussed hx of alcohol dependence – Informed pt of risk of ETOH during pregnancy – Advised cont’d abstinence – Advised to stop drinking – Encouraged commitment – Frequent appts to monitor – Frequent appts for tracking © Alcohol Medical Scholars Program 32

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 33

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 © Alcohol Medical Scholars Program 34

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 35

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 p. FAS © 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 © Alcohol Medical Scholars Program 37

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

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 39

© Alcohol Medical Scholars Program 40