Alcohol misuse in pregnancy

Dr Mosun Fapohunda and Dr Sanju George discuss treating alcohol misuse during pregnancy.

Recent epidemiological studies show that more women in the UK are now drinking at hazardous and harmful levels than ever before.1

However, it has been difficult to accurately estimate the prevalence of alcohol use and misuse among pregnant women. Alcohol misuse in pregnancy can adversely affect the woman, fetus, family and society.

From a health professional's perspective, it is crucial to remember that alcohol misuse in pregnancy often goes unrecognised and untreated.

 

Alcohol easily crosses the fetal blood–brain barrier and is teratogenic

Excessive alcohol intake
Excessive drinking can result in a range of physical, psychological and social consequences for a woman. Psychological effects of chronic alcohol misuse include aggression, depression, anxiety, deliberate self-harm and suicide.

Some of the social effects include crime and antisocial behaviour, impact on the partner (relationship problems, divorce, domestic violence), impact on children (neglect, abuse, developmental problems) and loss of productivity and profitability at work through alcohol-related absence.2

Fetal alcohol syndrome
Alcohol easily crosses the fetal blood-brain barrier and is a well-established physical and behavioural teratogen. Therefore a pregnant woman who consumes alcohol poses a specific teratogenic risk to the fetus - fetal alcohol syndrome (FAS).

FAS comprises the triad of facial dysmorphia, growth retardation and CNS deficits, and was first described in 1973. It is one of the leading causes of mental retardation worldwide; its neuro-behavioural and developmental abnormalities are irreversible.

Of course, FAS is completely preventable through avoidance of alcohol during pregnancy. This is where health professionals have a key role, in advising pregnant women to abstain from drinking.

Assessment and screening
Many pregnant women who drink alcohol will go through a normal pregnancy, have an uneventful labour and deliver a normal baby. Although alcohol misuse during pregnancy confers an increased risk on the outcome of pregnancy for mother and child, it is wrong to assume that alcohol misuse itself makes a woman incapable of caring for the baby.

Throughout the course of assessment and treatment, it is important to maintain a non-judgmental, empathetic and flexible approach.

A high index of suspicion is warranted in screening pregnant women with suspected alcohol dependence.

In non-specialist settings, and in patients with no clear-cut symptoms of alcohol dependence, simple screening tools are particularly useful.

These include CAGE, T-ACE and TWEAK (see boxes).

The CAGE questionnaire is short, simple and easy to use. It comprises four questions - two positive responses are considered a positive result and indicate a need for further assessment.

T-ACE is another simple, four-item questionnaire that is based on CAGE.3 TWEAK is a five-item scale developed originally to screen for risk during pregnancy.4

A score of two or more points indicates a likely risk of alcohol misuse.

Points to consider
A comprehensive assessment of the pregnant woman should focus on her alcohol use, her physical and psychological health, social circumstances and a risk assessment. Assessment of alcohol use should include the amount, frequency of use, reasons for continuation, symptoms of dependence, treatments tried, and previous contact with treatment services.

Physical, psychological, social, occupational, financial and legal consequences of alcohol use, if any, should be covered. Specifically, assessment of the woman's physical health should focus on general health, obstetric and gynaecological history, antenatal assessments and reports and nutritional status.

Psychological assessment should cover her feelings about the pregnancy and the baby, plans for the baby's future, feelings of guilt or self blame, fears about the baby being taken into care and so on.

Assessment of social needs include exploration of the following areas - employment, financial difficulties if any, legal situation, family, social support, housing (homeless or unsuitable accommodation), previous or ongoing contact with social services and parenting skills.

Finally, a risk assessment should be completed and this should encompass the risk to the physical and mental health of the mother during pregnancy, risk of FAS and childcare risk.

Treatment
There is no safe level of alcohol consumption in pregnancy, and given its potential for teratogenicity, the best advice is to stop drinking completely during pregnancy.

Most women who misuse alcohol will reduce or stop drinking either when planning to conceive or as soon as they find out they are pregnant.

Of those who continue to drink at hazardous levels, most will not need pharmacological intervention and hence psychological interventions are the treatment of choice. Brief psychological interventions can be effectively delivered in non-specialist settings and by a range of health professionals.

Other evidence-based, more structured psychological interventions for alcoholism include motivational enhancement therapy and Alcoholics Anonymous.5

Only those pregnant women who are alcohol-dependent will need drug-assisted detoxification. Benzodiazepines are the mainstay of medical detoxification, and the patient is closely monitored for alcohol withdrawal symptoms.

The pharmacological agents used to maintain abstinence and prevent relapse have not been evaluated for use in pregnancy and hence psychosocial treatment modalities take precedence over medication in this rehabilitative phase of alcohol dependence management.

  • Dr Fapohunda is a specialist trainee in psychiatry at the Queen Elizabeth Psychiatric Hospital, Edgbaston, Birmingham; Dr George is consultant in addiction psychiatry at The Bridge community drug team, Chelmsley Wood, Birmingham
  • 9 September is International Fetal Alcohol Syndrome Awareness Day. See www.fasday.com

Screening tools

CAGE - two positive responses indicate a need for further assessment

  • Cut down - Have you ever felt you should cut down on your drinking?
  • Annoyed - Have people annoyed you by criticising your drinking?
  • Guilty - Have you ever felt bad or guilty about your drinking?
  • Eye-opener - Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

TWEAK - a score of 2 points or more indicates risk of alcohol misuse4.

  • Tolerance - How many drinks can you hold? (3 or more drinks = 2pts)
  • Worried - Have close friends or relatives worried or complained about your drinking in the past year? Yes = 2 points
  • Eye-opener - Do you sometimes take a drink in the morning when you first get up? Yes = 1 point
  • Amnesia/blackouts - Has a friend or family member ever told you about things you said or did when you were drinking that you could not remember? Yes = 1 point
  • K(C)ut down - Do you sometimes feel the need to cut down on your drinking? Yes = 1 point

References

1. Plant M, Plant M. Binge Britain. Chapter 2. Drinking habits: recent patterns and trends. Oxford University Press, Oxford, 2006; 41-2.

2. Prime Minister's Strategy Unit. Alcohol harm reduction strategy for England. The Stationary Office, London, 2004.

3. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol 1989; 160: 863-70.

4. Russell M. New assessment tools for drinking in pregnancy: T-ACE, TWEAK and others. Alcohol Health Res World 1994; 18: 55-61.

5. Luty J. What works in alcohol use disorders? Adv Psychiatr Treat 2006; 12: 13-22.

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