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

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© Alcohol Medical Scholars Program3 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 © Alcohol Medical Scholars Program4

Cases Case 1 –27yo WF, 1 st 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, 2 nd preg –Recognition 4 wks –No psych hx –Pattern: 1 wine/night 1 glass/week w preg © Alcohol Medical Scholars Program5

DEFINITIONS © Alcohol Medical Scholars Program6

7 What is a Standard Drink?

© Alcohol Medical Scholars Program8 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 Medical Scholars Program9

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 Program10

Alcohol Abuse 1+ same 12 mos (if not dependent) of: –Role failure –Placing self hazardous situations –Legal problems –Social/interpersonal problems © Alcohol Medical Scholars Program11

Alcohol Use Disorder DSM-V (2013) Single list of 11 items Moderate: 2 or 3 criteria + Severe: ≥ 4 criteria + © Alcohol Medical Scholars Program12

RISK FACTORS © Alcohol Medical Scholars Program13

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 Program14

Who Drinks while Pregnant? Pre-pregnancy drinker Unmarried Comorbid psych and med dx Age ≥ 35 Less education © Alcohol Medical Scholars Program15

What about Our Cases? Case 1 Alcohol Dependence Case 2 No Alcohol Use Disorder © Alcohol Medical Scholars Program16

DRINKING EFFECTS IN PREGNANCY © Alcohol Medical Scholars Program17

Fetal Alcohol Effects - History 1600s: Sir Francis Bacon 1700s: UK gov’t, gin tax 1800s: Appearance of ETOH mothers’ infants © Alcohol Medical Scholars Program s: 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) © Alcohol Medical Scholars Program19

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 © Alcohol Medical Scholars Program20

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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 Program22

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 Program23

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 Program24

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 Program25

Neonatal Risk Factors Inadequate prenatal care Social isolation ↑ Stress © Alcohol Medical Scholars Program26

Lactation ACOG Committee opinion Breastfeeding after drinking: –↓ milk intake –↓ sleep & postnatal growth Don’t breastfeed for 3 hrs after ETOH © Alcohol Medical Scholars Program27

PREVENTION & TREATMENT © Alcohol Medical Scholars Program28

Prevention ABSTINENCE IS SAFEST Surgeon General statement Surgeon General recs © Alcohol Medical Scholars Program29

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 Program30

Brief Intervention Elements FACT –Feedback problem to patient –Advice re stop drinking –Commitment to keep monitoring –Tracking patient’s outcome © Alcohol Medical Scholars Program31

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 Program32

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 Program33

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 Program34

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 Program35

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 Program36

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 Program37

© Alcohol Medical Scholars Program38 Summary Alcohol + pregnancy = Concern Alcohol + pregnancy = Risk Abstinence is safest Screening essential Collaborative care key

Resources Alcohol’s Effects on the Body: Alcohol’s Effects on the Fetus: National Organization on Fetal Alcohol Syndrome: © Alcohol Medical Scholars Program39

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