Alcohol Use and Fetal Alcohol Syndrome

Here’s the RoshReview Question of the Week!

You respond to a precipitous vaginal delivery in the emergency department from a woman who has had no prenatal care. Following delivery, you notice the infant has abnormal facial features including low set ears, small eye openings, a flat nose, and an unusual-appearing upper lip. Which of the following was the fetus most likely exposed to?

• Alcohol

• Isotretinoin

• Lisinopril

• Methamphetamine

Check out the link above to find out if you have the right answer!

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Check out ACOG CO 496 for more on this topic!

We’ve talked before about opioid use, and also talked about some screening for substance use in primary care, but today we'll focus on alcohol use and abuse, and specific risks for pregnancy. 

Scope of the issue / definitions

• At-risk alcohol use: 3+ drinks per occasion, or more than 7 drinks in a week for women

  • Alternatively, any alcohol use for those who are pregnant or at risk of becoming pregnant

• Binge drinking: 3+ drinks per occasion

• Moderate drinking: 1 drink daily

  • 50% of binge drinking occurs amongst otherwise moderate drinkers

• Alcohol use disorder:

  • DSM-5 diagnosis of problematic alcohol use leading to clinically significant impairment or distress

• What constitutes “one drink” ?

  • Beer or wine cooler: 12 oz

  • Table wine: 5oz

  • Malt liquor: 8-9 oz

  • 80-proof liquor (40% ABV): 1.5 oz

    • Notably, “mixed drinks” can contain 1-3 or more drinks in a single serving!

• 28% of US adults fall into categories of unhealthy alcohol use, with 14% meeting criteria for alcohol use disorder.

• In pregnancy, 30% of pregnant folks report any alcohol use; 8% reported binge drinking on at least 1 occasion

  • This rate has been increasing in the last 20 years despite efforts to decrease it. 

• Alcohol use and risk for abuse in pregnancy is associated with other social risk factors, including:

  • AMA

  • Higher gravidity/parity

  • Inadequate prenatal care

  • Poor nutrition

  • Other substance use, including tobacco

  • Mental health problems

  • History of physical or sexual abuse, or IPV, or substance abuse by the partner/family

  • Social isolation, or living in rural areas during pregnancy

  • Poverty

Screening Tools to Identify at-risk drinking

Quantity based

• Can inquire about number of drinks in a typical week, or binge drinking episodes over the past three months -- if positive on either question, then know patient is at risk.

TACE if 2 or more points, indicates positive screen

• T - tolerance (how many drinks does it take to make you feel high?) 

• More than 2 drinks = 2 points

• A - annoyed (have people annoyed you by criticizing your drinking?)

  • Yes = 1 point

• C - cut down (have you ever felt you ought to cut down on your drinking?)

  • Yes = 1 point

• E - eye opener (have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?)

  • Yes = 1 point

AUDIT-C if 3 or more points, positive screen.

• How often have you had an alcoholic drink in past year?

• How many drinks did you have on a typical day when you were drinking in the past year?

• How often did you have six or more drinks on one occasion in the past year?

Important caveat - if someone is pregnant or considering pregnancy, any positive answer to these questions should prompt further discussion regarding patient’s attitudes towards alcohol in pregnancy.

Also important to recognize there may be a false-negative screen more likely in pregnant folks -- they may be reluctant to admit use due to fear of consequences/reprimand. There are some who argue that clinicians should always directly ask patients, as opposed to using electronic or paper-based screens.

**If screen positive -- 

• proceed with careful, non-judgmental assessment of drinking behavior

• Provide a brief intervention - non-judgmental counseling regarding risks and recommendation for abstinence 

  • RCTs have shown high success in reducing alcohol consumption by 33-60%, or increasing rates of abstinence from EtOH in pregnancy!

• If concern for alcohol use disorder, should be referred for professional alcohol treatment with psychiatry and medicine.

So what are the risks of EtOH use?

• Alcohol is a known teratogen, with effects dependent somewhat on amount, pattern of consumption, genetics, nutrition, and other maternal substance exposures (i.e., smoking, other drugs).

• There is no known safe “lower limit” of alcohol use!

  • Contrary to popular belief, international society guidelines have actually united in stating this. 

    • US, UK, France, Australia/New Zealand, Canada all have guidelines stating no safe limit for alcohol use.

  • 1st trimester exposure associated with significant facial and other structural anomalies as well as neurobehavioral effects and miscarriage

  • 2nd and 3rd trimester exposure increases risk for stillbirth, growth, neurobehavioral effects

• Stillbirth

  • Even after adjusting for confounders, any alcohol intake is associated with increased risk

    • 1.37 / 1000 births for <1 drink/week

    • 8.83 / 1000 births for 5+ drinks/week

• Fetal Alcohol Spectrum Disorders

  • Umbrella term encompassing a number of conditions, such as:

    • Fetal Alcohol Syndrome

    • Partial fetal alcohol syndrome

    • Alcohol related neurodevelopmental disorder

    • Neurobehavioral disorder associated with prenatal alcohol exposure

    • Alcohol-related birth defects

  • Estimated to affect 0.75% of pregnancies globally, with high prevalence in Europe and the US (1.5% in USA).

  • While we won’t review the specific diagnostic criteria, we can review some of the common features for each of these disorders that make up the criteria.

• Craniofacial anomalies (classic)

  • Short palpebral fissures

  • Thin vermillion border (i.e., thin upper lip)

  • Smooth philtrum (the typically indented area above upper lip)

• Other Anomalies

  • Ears: “railroad track ears” 

  • Hands: altered palmar crease (“hockey stick” of upper palmar crease)

  • Heart: CHD risk is about 2% (1% in gen pop) and can be highly varied

• Fetal growth restriction

  • Highly prevalent and part of most diagnostic criteria, with small growth persistent into childhood/adulthood

  • Estimates of 30-50% prevalence of FGR

• Neurodevelopmental outcomes

  • Small head size (HC<10%, occurring in up to 45%) or microcephaly (HC <3%, occurring in about 12%)

  • Other structural brain anomalies (~20%)

  • Recurrent non-febrile seizures

  • Impairment in gross motor function such as balance, coordination

  • Cognitive or intellectual deficits - generally lower IQ 

    • prev of IQ < 70: 8% with prenatal alcohol exposure, 20% if full FAS

  • Developmental delays

  • Neurobehavioral impairments (i.e., sensory processing, self-regulating behavior)

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