Alcohol in Pregnancy the hidden impact

November 11th 2011

Alcohol in our Society

• Acceptable drug• Not perceived as harmful• “I’m not at risk”• Binge drinking common and acceptable• Women drinking as much or more than men• Now significant cause of death in young women

Background

• Consumption of alcohol amongst women is high

• Teratogenic

• Fetotoxic

• Consumption is underreported

• Identification of women at risk important

Effects of Alcohol in Pregnancy

• Lemoine et al first described effects in 1963• 1973 term Fetal Alcohol Syndrome (FAS) used to

describe the facial characteristics, growth impairment and neurobehavioural function in children exposed prenatally to alcohol

• Fetal Alcohol Spectrum Disorder (FASD) encompasses children exposed prenatally to alcohol with the behavioural problems with or without the phenotype of fetal alcohol syndrome

Most widely used teratogen world wide

Extent of the problem

• Best data from Canada and United States• FAS 0.6/1000 live births in Canada• FASD 9/1000 in United States• 128 children were diagnosed with FAS in UK 2002-2003• Estimate 1:100 babies born in UK with FASD• Leading cause of preventable birth anomalies and

disability• No reliable incidence and remains under diagnosed.

How does alcohol cause the problem?

• Ethanol is a well recognised animal and human toxin which freely crosses the placenta.

• It has a direct effect on neurones causing cell death and inhibiting normal cell adhesion thus affecting migration, fasciculation and synaptogenesis

• Charness et al showed this occurs at low levels of exposure in animal studies

How does alcohol cause the problem?

• The concentrations are as high in the fetus as the mother and the fetus has limited ability to metabolise alcohol

• Direct effect on placenta and umbilical cord with subsequent poor blood flow and hypoxia

• Growth retardation, miscarriage and stillbirth

Brain DamageCellular Damage

Structural Malformation or Arrested Development

Cognitive and Functional Impairment

Poor memory, attention deficits, impulsive behaviour, and poor cause-effect reasoning

Predisposition to Mental Health Problems

Central nervous system

• structural impairment

• neurological impairment

• functional impairment

Structural1St Trimester (Migration / Organisational Interferance)• Microcephaly (two or more standard deviations below the average)• Agenesis of Corpus Callosum• Cerebellar Hypoplasia

3rd Trimester• Hippocampal Damage (memory, learning, emotion, and encoding visual and

auditory information)

NeurologicalDamage to the CNS and the PNS.• hard signs • diagnosable disorders

– epilepsy or other seizure disorders

• Soft signs – impaired fine motor skills– neurosensory hearing loss– poor gait – clumsiness– poor eye-hand coordination.

Alcohol Related Birth Defects• Cardiac

– Murmur– VSD / ASD.

• Skeletal – Joint anomalies – altered palmer crease patterns – small distal phalanges– small fifth fingernails.

• Renal– Horseshoe – aplastic – Dysplastic– hypoplastic

• Ocular

Alcohol Crosses Placenta

Fetal Growth RestrictionBrain DamageDistinctive Facial

StigmataPsychological or

Behavioural ProblemsOther Physical Problems

Alcohol-Related Neurodevelopmental Disorder

(Partial) Fetal Alcohol Syndrome

Alcohol Related Birth Defects

Growth deficiency "4-Digit Diagnostic Code:"

• Severe — Height and weight at or below the 3rd percentile.

• Moderate — Either height or weight at or below the 3rd percentile, but not both.

• Mild — Both height and weight between the 3rd and 10th percentiles.

• None — Height and weight both above the 10th percentile.

Craniofacial abnormalities

• caused mainly between the 10th and 20th week of gestation.

Craniofacial abnormalities

• caused mainly between the 10th and 20th week of gestation.

3 Cardinal Facial Features

• A smooth philtrum

• Thin vermilion

• Small palpebral fissures

Ranking of FAS Facial FeaturesSevere All three facial features ranked independently as severe (lip ranked at 4 or 5, philtrum ranked at 4 or 5, and PFL two or more standard

deviations below average).

Moderate Two facial features ranked as severe and one feature ranked as moderate (lip or philtrum ranked at 3, or PFL between one and two standard deviations

below average).

Mild A mild ranking of FAS facial features covers a broad range of facial feature

combinations: – Two facial features ranked severe and one ranked within normal limits, – One facial feature ranked severe and two ranked moderate, or – One facial feature ranked severe, one ranked moderate and one ranked within

normal limits.

None All three facial features ranked within normal limits.

Functional– Deficits– Problems– Delays

in observable and measurable domains related to daily functioning

Learning/ Memory / MathsImpulse ControlSocial Perception/ Adaptive SkillsCommunication/ LanguageSocial SkillsCognition

Fetal Alcohol Syndrome

• While the ingestion of alcohol does not always result in FAS, there are no medically-established guidelines for safe levels of alcohol consumption during pregnancy.

What is safe?

• Controversial

• United States, Canada, Australia, New Zealand

NO SAFE LIMIT

What is safe?

• BMA report ‘Fetal Alcohol Spectrum Disorders’ June 2007 states that abstinence is the only safe policy for women who are pregnant or planning a pregnancy

• Unlike genetic causes of disability it is preventable• Department of Health updated their guidance and

came to same conclusion as BMA.

What is safe?

• RCOG Statement No. 5 March 2006, NICE Antenatal Care Guideline agree alcohol has an adverse affect on fetus but state there is no evidence of harm from low levels of alcohol consumption. RCOG defined this as ‘no more than 1 or 2 units once or twice a week’.

NICE Antenatal Care March 2008 (Guideline 62)

• 5.12 Alcohol and smoking in pregnancy• Alcohol consumption in pregnancy:• Pregnant women and women planning a pregnancy should be

advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage.

• If women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week (1 unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units).

NICE Antenatal Care March 2008 (Guideline 62)

• Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.

• Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.

Under reporting

• Feel guilty about alcohol use

• Fear of being judged

• Fear of losing baby and/or other children

• Professionals don’t ask the right questions

Factors that Determine Impact

timing of alcohol consumptionfrequency of alcohol consumption

dose of alcohol consumptiongenetic predisposition

Women at higher risk of fetus with FAS

• Low income• Low literacy• Minority status• Unplanned and unwanted pregnancies• A previous child with FAS or related diagnosis• Frequent binge drinkers• Remember students and women of high

socioeconomic status

What should we do?

• ASK, ADVISE, ASSIST• How much alcohol do you drink?• Prepregnancy best time• Screening at booking• Advise it is safest to stop drinking• If unable to stop encourage to reduce• Refer for further support and continue follow up

Management of alcohol withdrawal

• Starts 6-48 hours after drinking stops• Symptoms may include

– Autonomic hyperactivity, sweating, tremors, anxiety, insomnia and seizures

• Alcohol is eliminated at less than one unit per hour and detoxification is usually complete after 72 hours

• Patients should be admitted and treated medically• Need ongoing support and follow up

Breastfeeding

• Alcohol is passed to baby in mother’s milk but time dependent from consumption

• Similar to levels in blood at time of feeding

• Occasional drink not shown to be harmful but better to feed 2 hours after one drink

Adverse effects on nursing infants

• With excessive alcohol intake– Impaired motor development– Changes in sleep patterns– Decrease in milk intake– Risk of hypoglycaemia

Conclusion

• Consensus that alcohol is dangerous for both the pregnant woman and her baby

• No consensus on a safe limit• Excess drinking under detected in pregnant women• FAS and FASD remain under diagnosed but are the

leading cause of preventable birth anomalies and disability

• Consider this diagnosis in children• Health professionals need to improve detection and

support

nofas-uk.org