Alcohol

Safe Drinking Levels

> No safe threshold for maternal alcohol intake. > Abstinence is recommended during pregnancy > Women can be reassured that adverse fetal effects have not been    demonstrated with mild social drinking before realizing they were pregnant

Screening and Identification

> Ask about number of standard drinks per day and per week. > 1 standard drink = 1 bottle beer, 5 oz wine, 1 1/2 ounce liquor > Ask about maximum consumption on any 1 day since pregnancy began. > Order GGT and MCV if alcohol use suspected (sensitivity 50% for 4 or more    drinks per day) T-ACE screening questionnaire T  Tolerance: How many drinks does it take for you to feel an effect? A  Have people Annoyed you by criticizing your drinking? C  Have you felt you ought to Cut down on your drinking? E  Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?      (Eye-opener) Scoring T: 2 points if it takes more than 2 drinks to make her feel "high" A,C,E: 1 point for each "yes" A total of 2 or more points indicates that the woman likely has an alcohol problem (requires further assessment for diagnosis)

Symptoms and Signs of Withdrawal

> Common in women drinking 6 or more drinks per day > Onset 8-12 hours after last drink, peaks 24-72 hours, may last 7 days > Tremor (postural, intention), ataxia, sweating are most reliable signs > Other signs: hypertension, tachycardia, gastrointestinal upset, anxiety > Complications: seizures (grand-mal, non-focal, brief), hallucinations, arrhythmias, delirium tremens

Management of Withdrawal

> Admit to hospital > Monitor hydration status and rule out electrolyte imbalance > Monitor for non-reassuring fetal status > Folic acid 5mg po od > Thiamine 100 mg po od x 3 days > If not in labour, treat with diazepam 20 mg po q 1-2 h until minimal tremor; ongoing treatment not    usually needed During labour: > Notify neonatology/paediatrics: benzodiazepines can cause "floppy baby syndrome" > Use lorazepam 2-4 mg sl, po q 2-4 h prn

Fetal Effects

Fetal Alcohol Spectrum Disorder (FASD)    Includes Fetal Alcohol Syndrome and other alcohol-related birth defects and neurological disorders Prevalence of Fetal Alcohol Spectrum Disorder:    ~1 in 100 live births Prevalence of Fetal Alcohol Syndrome:    ~1 in 1000 live births (general population): 4-5% in heavy drinkers Features of FAS include: > Growth restriction > Characteristic facial anomalies, e.g., microcephaly,micrognathia, short palpebral fissure, flat philtrum > Central nervous system abnormalities, developmental delays, brain malformations, intellectual    impairment, behavioural problems > See guideline on diagnosing FASD in CMAJ 2005; 172 (5suppl.): S1-S21 (www.cmaj.ca) Other complications of alcohol: > Spontaneous abortion > Fetal compromise

Neonatal Effects

> If mother intoxicated at time of delivery, assess neonate for withdrawal

Breastfeeding

> Alcohol enters breast milk and infants are exposed to a fraction of the alcohol ingested by the mother > Potential adverse effects include: impaired motor development in child and decreased let-down reflex and    suppressed lactation in mother > An acceptable level of alcohol in breast milk has not been established > With moderate, occasional alcohol use: delay nursing for 1-2 hours per drink to minimize infant exposure;    heavy alcohol consumption while breastfeeding should be avoided while breastfeeding

Management of Alcohol Dependence

> Behavourial interventions recommended > Pharmacotherapy can help to maintain abstinence e.g., anti-craving (naltrexone and acamprosate) and    aversive (disulfiram) agents

Anti-alcohol Drugs

> Disulfiram: acetaldehyde dehydrogenase inhibitor;teratogenic, contraindicated in pregnancy > Naltrexone: opioid receptor antagonist; safety not established in pregnancy; use only if behavioural                            treatment has failed and benefit outweighs risk > Acamprosate: glutamate modulator; safety not established in pregnancy, use not recommended                                in pregnancy