1. Fetal Alcohol Syndrome Anita Olejek
Regional Consultant for Gynaecology and Obstetrics, Silesia, Poland
Medical University of Silesia

2. Definition
Fetal Alcohol Syndrome (FAS) is a disorder that can occur to the embryo when a pregnant woman ingests alcohol during pregnancy.

3. History
The earliest known observation of possible links between maternal alcohol use and fetal damage was made in 1899 by Dr. William Sullivan, a Liverpool prison physician
He noted higher rates of stillbirth for 120 alcoholic female prisoners than their sober female relatives; he suggested the causal agent to be alcohol use

4. History
Later on, it has been repeatedly noted, that children born by mothers addicted to alcohol had:
excessive mortality in the early childhood,
high incidence of epilepsia
signs of mental retardation
physical abnormalities
These facts were already noted in the 19th centrury, however the interest in this topic decreased during the Prohibition period ( ).

5. Early research
First scientific discoveries identifying the syndrome were performed in 1968, when Lemoine from Nantes (France) published the results of his research
He followed the children of the heavily drinking mothers for almost 30 years
This is a first time when this syndrome has been really described
The term „Fetal Alcohol Syndrome” has been hovewer introduced later

6. Recognition as a syndrome
Fetal Alcohol Syndrome was named in 1973 by two morphologists, Jones and Smith of the University of Washington in the United States
They identified a pattern of "craniofacial, limb, and cardiovascular defects associated with prenatal onset growth deficiency and developmental delay" in eight unrelated children of three ethnic groups, all born to mothers who were alcoholics
The pattern of malformations indicated that the damage was prenatal.

7. What do we know today? Development of FAS is dependent on many factors
Important is: frequency of drinking, alcohol intake, part of pregnancy most exposed to drinking, nutritional status and concomitant use of various drugs
Genetic predispositions may have a limited, but also significant influence
Each etnic and racial group is equally at risk
General health status of the pregnant woman is essential. Healthy lifestyle is extremely protective.

8. There is no such thing as „safe drinking”in pregnancy
Even a small amount of regular drinking may lead to the development of FAS.

9. Typical clinical picture

10. The following criteria must be met to confirm a diagnosis of FAS:
Growth deficiency - Prenatal or postnatal height or weight (or both) at or below the 10th percentile
FAS facial features - all FAS facial features present
Central nervous system damage - clinically significant structural, neurological, or functional impairment
Prenatal alcohol exposure - confirmed or unknown prenatal alcohol exposure

11. FAS facial features
A smooth philtrum - the divot or groove between the nose and upper lip flattens with increased prenatal alcohol exposure.
Thin vermilion - the upper lip thins with increased prenatal alcohol exposure.
Small palpebral fissures - eye width decreases with increased prenatal alcohol exposure.

12. In some cases, facial deformations are seen already at birth or in the early childhood

13. Central nervous system damage
three areas: structural, neurological, and functional impairments
structural impairments may include microcephaly (small head size), or other abnormalities in brain structure
neurological impairment may be classified into hard signs (epilepsy or other seizure disorders) and soft signs (such as impaired fine motor skills, neurosensory hearing loss, poor gait, clumsiness, poor eye-hand coordination, or sensory integration dysfunction)
functional impairment is often referred to as developmental disabilities and includes: learning disabilities, academic achievement, impulse control, social perception, communication, abstraction, math skills, memory, attention and judgment.

14. Related signs
stemming from prenatal alcohol exposure. However, these conditions are considered Alcohol-Related Birth Defects and not diagnostic criteria for FAS.
Includes:
Cardiac - a heart murmur that frequently disappears by one year of age.
Skeletal - joint anomalies including abnormal position and function, altered palmar crease patterns, small distal phalanges, and small fifth fingernails.
Renal - aplastic, dysplastic, or hypoplastic kidneys.

15. Apart from all these symptoms, there is an intelectual and emotional impairment

16. Related disorders
Fetal Alcohol Effect (FAE) – used when drinking in pregnancy is documented and some FAS criteria are present
Alcohol Related Neurodevelopmental Disorer (ARND)
Fetal Alcohol Related Conditions (FARC)
Alcohol Related Birth Deformations (ARBD)

17. Neuropsychological disturbances
memory
coordination
reading and writing
concentration
speech
motivation
mood

18. Research performed on 61 young patients with FAS was able to demostrate, that levels of IQ were generally not that bad (68, while 2.5% of the general population has IQ around 70).
Recognition of words was acceptable, but reading with understanding was much worse in all the tests performed.

19. FAS in the early childhood
Many children are born with signs of “delirium tremens” - this indicates a potential of epilepsia in the nearest future.
As newborns, children with FAS may have impaired coordination and abnormal sleep patterns.
Later in their childhood, they may have problems with concentration, cannot distinguish colours and assess time. Their vocabulary is very poor.

20. FAS later on...
At school, children with FAS usually experience major problems, even if their IQ is average or only slightly below that value.
Such children cannot assess the situation properly and predict the consequences of their behaviour. They also do not learn from mistakes.
They ignore warnings and require continuous repetition of the given instruction. Lack of thank discourages people trying to guide them.

21. Important issue!
Children with FAS are easily involved in minor crimes, inappropriate sexual behaviour and alcohol or drug abuse.
This is the main reason why women with FAS have a higher probability to have children with FAS (but FAS is not a genetic, inherited disorder!)

22. Fetal Alcohol Effect (FAE)
Not all the children born from mothers who drunk alcohol during the pregnancy have a full-blown FAS syndrome. If drinking is sporadic, physical and mental abnormalities may not be easily traced.
Children may have normal IQ but serious problems at school.
Such “uncomplete” syndrome is sometimes referred as Fetal Alcohol Effect (FAE).

23. Management of FAE very complicated
level of intelligence actually normal
patterns of social behaviour abnormal
such people, even if their IQ is satisfactory, should only work under a strict supervision, and have to be constantly controlled.

24. Epidemiology of FAS
Most reliable research in the USA shows that there are births of children with FAS every year
That means that on the average there are 3/1000 (0.3%) live births of children with FAS (for women known to be alcoholic this figures are 2.5%).
In the United States, FAS is a leading cause of mental retardation, apart from Down’s syndrome.

25. Epidemiology of FAE Lack of reliable data
It is concluded that up to 8-10% of all cases of mental retardation in the USA may be due to FAS.
In the Indian reserves (where alcoholism is an epidemic) as much as 25% of children may have some symptoms of FAE.

26. Situation in Silesia Largely unknown
There are no data on the real amount of women drinking alcohol during pregnancy (no records)
Main reasons – women who drink excessive alcohol when pregnant feel shame and accuse themselves but do not report this to the physician
They also fear of repressions from their social enviroment

27. What could be done?
Observation shows that most women are aware of the fact that drinking in pregnancy is dangerous.
Public education campaign may discourage moderately drinking women
This is however not effective in heavily drinking and alcoholics. Women from these groups are best treated directly by their physicians.

28. Limitations
Unfortunately, physicians feel constrained and ashamed to ask women for their alcohol problems.
Institutions taking care of pregnant women should therefore create systematic, problem-specific questionnaires exploring the problem of alcohol intake during pregnancy. This information should be later transferred to patient’s records.

29. Animal studies suggest that pregnancy is more at risk when alcohol is given in large single doses (occasional binge drinking).
Moreover, the consequences of heavy drinking in the early
pregnancy may persist even if drinking was completely
stopped in the second and third trimester.

30. Consequences of alcohol intake in pregnancy
First trimester:
Brain damage
Attenuation of cell development
Heart and kidneys damage
Face deformation
Abortion
Second trimester:
Attenuation of brain development
Damage of muscles, skin, bones, teeth
Abortion
Third trimester:
Attenuation of brain and lungs development
Attenuation of growth

31. No one knows what amount of alcohol is safe for a pregnant woman
This is why women are advised to stop drinking alcohol completely during pregancy