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Pregnancy Support

These pages outline the risks of alcohol consumption in pregnancy, and gives an introduction to Foetal Alcohol Spectrum Disorder and some strategies for brief interventions. In the very near future this resource will grow, more useful information will appear in the training section for workers.

Overview:

Welcome to the Alcohol and Pregnancy Self Learning Package. This package outlines the risks of alcohol consumption in pregnancy, and gives an introduction to Foetal Alcohol Spectrum Disorder and some strategies for brief interventions.

Concern about alcohol consumption is not new but the recommended levels of alcohol consumption have never been clear cut, this has been confusing for pregnant women and professionals alike.

The message to pregnant women is that there is no safe level of alcohol consumption in pregnancy and no safe time during to drink alcohol during pregnancy.

Aim:

The aim of this package is to increase knowledge and awareness about the risks of alcohol use in pregnancy.

Objectives

On completion of this package participants will be able to:

  1. Define a standard drink
  2. Identify levels of alcohol consumption that may result in harm
  3. Discuss the recommendations for alcohol consumption in pregnant women
  4. Define Foetal Alcohol Spectrum Disorder
  5. List the features of FAS
  6. Outline how to ask a woman about alcohol use
  7. List harm minimisation strategies for pregnant women who choose not to abstain from alcohol

Self Assessment Requirements

To successfully complete this package you will need to complete a quiz at the end.

Throughout this package you will find reflective questions, references for extra reading and useful websites

Introduction

Alcohol use is widely accepted practice in western society and is often associated with social occasions and celebrations. Research has indicated the benefits of small amounts of alcohol consumption, but excessive use may result in harm.

Trends in society have changed dramatically this has seen the birth of ‘ladettes’ and binge drinking behaviour amongst young women.In comparison to men, women are more susceptible to the harmful effects of alcohol. Concerns about ongoing alcohol in pregnancy are not new. Foetal Alcohol Syndrome (FAS) is the biggest PREVENTABLE cause of birth defects and brain damage in unborn children. Research has failed to indicate a safe level of alcohol consumption during pregnancy and the effects of alcohol will vary between women. A prudent approach is to advise pregnant women or those considering pregnancy to abstain from drinking alcohol. Women who choose not to abstain from alcohol should be encouraged to follow the UK guidelines (DOH Oct 2006) and should be offered brief intervention to reduce their alcohol intake and avoid the risk of intoxication during pregnancy.

UK Alcohol Guidelines (DOH 2006)

A standard drink is:

  • ½ pint of 4% lager
  • 1 (25ml) shot of spirit
  • 1 small glass of wine (100mls)

To minimise the health risks and gain any long term benefits to health the DOH recommends that:

Men

  • Exceed no more than four standard drinks a day on average
  • Exceed no more than six standard drinks in one day
  • Have one or two alcohol free days per week

Women:

  • Exceed no more than two standard drinks a day on average
  • Exceed no more than four standard drinks on any one day
  • Have one or two alcohol free days per week

Risks associated with alcohol consumption

There is evidence to suggest that low levels of alcohol use by middle aged people can prevent cardio vascular disease; however it is not necessary to drink alcohol to obtain such benefits. Healthy lifestyle practices, such as diet and exercise can result in the same benefits and it is recommended that younger people use these practices rather than alcohol to reduce their risk of cardiovascular disease. There is no evidence to suggest that alcohol consumption above the recommended levels will result in any benefits to health. In fact drinking above this level is likely to increase the risk of health problems.

Alcohol and Women

Women are at greater risk of harm from drinking excessive alcohol for a number of reasons (National centre for Education and Training on Addiction 2004) In comparison to men, women usually have a smaller liver and body frame with a higher percentage of body fat, resulting in a reduced ability to metabolise alcohol. Excessive use leading to intoxication can place women at greater risk of injury and assault.

Risk factors for those women who drink hazardous and harmful amounts of alcohol

  • A family history of alcoholism or excessive use
  • Behaviour problems such as impulse control
  • Difficulty coping with stressful life events
  • Depression, divorce and separation
  • Having a drinking partner
  • Employment in a male dominant environment or profession

Women are less likely, than men to seek problems for alcohol related problems. Reasons for this include the perception of stereotypical attitudes towards female drinkers, depression and concerns about children being taken in to care.

Alcohol and Pregnancy

When a pregnant woman drinks alcohol it crosses the placenta to her baby in concentrations similar to that in the maternal blood stream. In the Embryo and foetus the developing cells are susceptible to the teratogenic effects of alcohol. Compared to other developing cells, the cells of the Central Nervous System have a lower threshold for alcohol and experience a more rapid cell death, usually as a result of necrosis (Duty, Chen, Sucker, Dehart, and Sulik, in Welch-Carre 2005). The fetus is most vulnerable to damage from high risk drinking in the first few weeks of pregnancy, when the woman may not realise she is pregnant. Pregnancy problems associated with alcohol use include antepartum haemorrhage, miscarriage, foetal death in utero and pre term labour.

It is recommended that pregnant women or those considering pregnancy:

  • Consider not drinking at all
  • Never become intoxicated
  • If they choose to drink consume no more than seven standard drinks over a week and consume no more than two standard drinks in any one day. (spread over at least two hours)
  • Should note the risks are higher in the earliest stages of pregnancy, including the time from conception to first missed period.
  • Women with high blood pressure or poor nutrition should be encouraged to avoid alcohol.

Did you know?

Concern about the effect of drinking alcohol in pregnancy is not new and women have been advised not to drink in pregnancy as far back as Biblical Times

Alcohol and Breastfeeding

Did you know?

One unit of Alcohol takes about two hours to clear from a mother’s milk

Alcohol passes through to the baby in small amounts through breast milk. Alcohol use may also reduce milk supply.

It is recommended that women who are breastfeeding consider not drinking at all or follow the guidelines stipulated for pregnancy.

Alcohol in breast milk may:

  • Cause milk to smell differently, thus putting the baby off feeding
  • Make baby too sleepy to feed
  • Disrupt sleeping patterns of the baby and cause digestive difficulties

Foetal Alcohol Syndrome

Concerns about the effect of alcohol on the developing foetus are not new. FAS is now considered to be the leading cause of preventable intellectual handicap (O’Learey 2002)

FAS is a term that is used to describe a combination of abnormalities that include craniofacial, extremity and cardiovascular anomalies, as well as growth defects and developmental delays. The syndrome first described by Jones, Smith, Ulleland and Streissguth (1973) includes:

  • Developmental delay including motor and social impairment
  • Microcephaly
  • Growth restriction- during the antenatal period and after birth
  • Presence of facial features as small palprebal fissures (small eye opening), thin upper lip, smooth philtrum
  • Central nervous system disorders
  • Cardiac anomalies
  • Confirmed alcohol exposure may or may not be present (i.e. a history of alcohol use during pregnancy may be difficult to determine for those children who have been adopted or placed in foster care)

FAS cannot be diagnosed by a laboratory test, but relies on clinicians identifying distinguishing features or abnormalities that make up the syndrome, usually in conjunction with a history of alcohol use/misuse at the time of conception and throughout pregnancy. Individual abnormalities can be subtle and difficult to detect, hence some diagnosis may be a problem in the absence of a history of alcohol use (O Leary 2004). The facial characteristics of FAS are often subtle in the neonate and can be confused for other syndromes (Wilson and Bass 2003). Diagnosis is usually made in infancy and early childhood, as the features of FAS change with age and central nervous system dysfunction and facial morphology may be difficult to assess prior to two years of age. It has proven difficult to provide quantitative diagnostic criteria for FAS, but over time the syndrome has been consistently described to have four main features, these being:

  • A confirmed diagnosis of maternal alcohol consumption
  • Facial characteristics
  • Growth restriction
  • CNS abnormalities

Antenatal exposure to alcohol does not necessarily result in FAS and research is unclear as to what level of alcohol consumption is considered to be safe. While one woman may drink alcohol during pregnancy and her baby is affected, another may consume similar levels and hers is not. Effects of alcohol during pregnancy depend on the dose, timing and conditions of the exposure, as well as the individual characteristics of the mother and foetus (Streissguth 1977). Research is limited in this area, due to the risk of alcohol to the fetus; studies are limited to longitudinal cohort and case studies, which may be subject to a range of bias.

FAS is usually seen in infants of women who have a history of chronic daily alcohol use or intermittent binge drinking (O’Leary 2004).

Not all children affected by antenatal alcohol exposure will display all the characteristics of FAS and the amount of alcohol required to produce partial FAS has not yet been quantified. Partial FAS or Foetal Alcohol Effects (FAE) refers to a condition where the child displays some of the symptoms of FAS, but does not meet the full diagnostic criteria, but there is evidence of CNS abnormalities, growth deficiency and behavioural dysfunction. FAE is a term that is now discouraged as it is ambiguous. Other terms that may be used to describe children who display some, but not all of the characteristics of FAS include:

  • Alcohol related birth defects (ARBD)
  • Alcohol related neurodevelopmental disorder/ effect (ARND)
  • Partial FAS
  • Foetal Alcohol Spectrum Disorder (FASD)

Want to know more?

Nofas-uk@midlantic.co.uk Foetal alcohol syndrome A literature review Covers the history of FAS, alcohol as a teratogen, diagnosis and more.

You can find it online at: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-publicat-document-fetalcsyn-cnt.htm/$FILE/fetalcsyn.pdf

Asking about alcohol use

The level of Alcohol consumed is an important determinant of whether a woman is at risk of causing long term harm and the likelihood of alcohol withdrawal. Early identification of likely problems will influence appropriate choices for intervention (De Crispigny etal 2003)

Asking about alcohol use can be incorporated in to a routine history when discussing other lifestyle factors such as diet and smoking. It is reasonable to presume that most people drink alcohol, so this may be introduced as a normal practice. Specific questions focussing on the current week’s drinking patterns should be used.

For example:

How often do you have a drink during the week? And, On the weekend how much do you drink?

Phrases such as social drinker and occasional drinker should be avoided as they are ambiguous and do not quantify the exact level of alcohol consumed.

If the woman is not specific then clarify with further questions to determine the exact amount of alcohol she consumes.

De Crespigny (etal 2003) use examples such as:

  • What is the size of the bottle / glass/ cask
  • How often would you drink this amount?
  • Do you drink this amount every day?

Reflection Questions

  • How do you usually raise the issue of alcohol use with pregnant women?
  • How do you clarify the amount of alcohol consumed when taking a history?
  • Do you discuss strategies to reduce alcohol intake in pregnancy?
  • Is there anything you could do to improve?
  • Do you see any barriers to improving your responses?

Early and Brief Interventions

It is reasonable for health professionals to advise pregnant and breastfeeding women not to consume alcohol at all. However for women who choose not to abstain from alcohol during pregnancy, brief intervention can encourage them to reduce consumption to a low level and reduce the risk of long term harm. Providing information about alcohol and its effects during pregnancy and outlining some strategies may be enough to encourage the woman to reduce or abstain from alcohol during pregnancy.

Harm Reduction Strategies

These may assist to reduce the risk of intoxication (DeCrespigny etal 2003)

  • Remember there is no safe level of alcohol consumption during pregnancy
  • Drink no more than the recommended level of alcohol (seven standard drinks per week in pregnancy, no more than two standard drinks per day)
  • Know how much you are drinking- have drinks in a standard size glass
  • Have non alcoholic drinks between alcoholic drinks
  • Eat before drinking
  • Try low alcohol alternatives ( light beer, add soda to wine)
  • Quench thirst with water and soft drinks
  • Avoid top – ups
  • Plan social activities that don’t include alcohol

Reflection Question

Oliver was born by emergency c/section for fetal distress. His apgar score at 1minute was low, but he responded to basic resuscitation. 24 hours after birth he was having difficulty feeding and the midwife noticed he was jittery, lethargic and drowsy. The drinking status of Oliver’s mother was recorded antenatally in her medical notes as “Social drinker” when infact she did not disclose that she consumed 21 standard drinks per week. How could this situation have been avoided? How may Oliver’s care differ if this information was available?

Alcohol Withdrawal

For women where alcohol dependence has not been realised, withdrawal can start within 12 hours after the last drink and the severity may be classified as mild, moderate or severe. Due to falling blood alcohol levels, early signs usually appear between 6-24 hours. The delirium tremens (or DT’s) is the most severe form of alcohol withdrawal and is a medical emergency.

Index of suspicion (De Crespigny etal 2003)

  • History of heavy drinking and it is less than 10 days since alcohol last consumed
  • A regular daily intake of eight standard drinks for men six for women
  • Lower levels of alcohol than those outlined above) are consumed in conjunction with other central nervous system depressants
  • Past history of alcohol withdrawal seizures or other serious symptoms
  • Current admission is due to an alcohol related condition
  • Physical appearance indicating harmful alcohol use (e.g. Facial vascularisation, signs of liver disease)
  • Signs and symptoms that are consistent with alcohol withdrawal
Symptom Mild Moderate Severe
Temperature Mild rise Mild rise Fever
Tremor Slight Slight  
Sweating Mild Moderate Excessive
Psycho-social Mild anxiety
  • Moderate anxiety- but will respond to reassurance
  • Hyperventilation and panic
  • Restlessness and agitation
  • Acute anxiety may/ may not respond to reassurance
  • Agitation Hyperventilation and panic
  • Disorientation and confusion
  • Hallucinations
  • Hypersensitivity to stimuli
Sleep disturbances Insomnia
  • Insomnia
  • Nightmares
 
Gastrointestinal
  • Nausea and vomiting
  • Dyspepsia
  • Nausea and vomiting
  • Diarrhoea
  • Dyspepsia
  • Anorexia

Nausea and vomiting Diarrhoea

Cardiovascular
  • Mild hypertension
  • Headache

Mild to moderate hypertension

  • Moderate to severe hypertension Or Hypotension
  • Tachycardia
other Mild dehydration
  • Dehydration
  • Headache
  • Weakness
  • Dehydration
  • Convulsions/ seizures
  • (withdrawal seizures can be life threatening and are usually avoidable)

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