Alcohol Use in Pregnancy Melanie McKean, D.O., Ph.D.

Alcohol Use in Pregnancy Melanie McKean, D.O., Ph.D. Department of Neurology and Psychiatry Saint Louis University http://clutchmag.s3.amazonaws.com/wp-content/uploads/2012/06/Alcohol-in-pregnancy-copy-533x800.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 27yo WF, 1st pregnancy Recognition 10 wks H/O depression Pattern:

2-5+ drinks/night Case 2 36 yo AAF, 2nd preg Recognition 4 wks No psych hx Pattern: Blackouts 1 wine/night

Drinks for same effect 1 glass/week w preg 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% dont 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 Alcohol Dependence Alcohol Medical Scholars Program Case 2 No

Alcohol Use Disorder 16 DRINKING EFFECTS IN PREGNANCY Alcohol Medical Scholars Program

17 Fetal Alcohol Effects - History 1600s: Sir Francis Bacon 1700s: UK govt, 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 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 pFAS 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 1st 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

Dont 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 patients outcome http://www.sciencemediacentre.co.nz/wp-content/upload/2012/06/PregAlcohol1.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 contd abstinence Advised to stop drinking Encouraged commitment 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 pFAS 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 Alcohols Effects on the Body: http://www.niaaa.nih.gov/alcohol-health/alcohols-effects-body Alcohols Effects on the Fetus: http://www.niaaa.nih.gov/alcohol-health/fetal-alcohol-exposure National Organization on Fetal Alcohol Syndrome: http://www.nofas.org/

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