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?

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

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)

Fecal Incontinence

/

Here’s your RoshReview Question of the Week!

Which of the following physical exam findings would be present in a woman with fecal incontinence and disruption of the external anal sphincter?

Find out the right answer by clicking on what you think the answer is, and find out how to save 20% on a RoshReview QBank Subscription for CREOG studying!

What is Fecal Incontinence? 

  • Definition

    • Part of accidental bowel leakage - where there is loss of normal control of the bowels. The other aspect of ABL is leakage of stool and gas (anal incontinence) 

    • Fecal incontinence - specifically is leakage of stool 

    • National Health and Nutritional Examination Survey defined it as: loss of solid or liquid stool or mucus at least once in previous 30 days 

  • How common is it?

    •  NHANES survey; 8.3% prevalence (in 4308 community dwelling adults 

    • Prevalence increases with age (2.6% in 20s to 15.3% in adults 70 and older) 

    • Likely underestimated since 75-80% of individuals with fecal incontinence don’t seek help or report them to their health care provider 

  • Risk factors 

    • Loose or watery stool 

    • Increased frequency of stools (more than 21 a week) ← ok, who is pooping more than 3x a day, and how can I get to this level of regularity  

    • Having 2 or more chronic illnesses 

    • Urinary incontinence, obesity, smoking, increasing age, decreased physical activity, anal intercourse, history of OASIS, history of pelvic radiation

What are the causes of fecal incontinence? 

  • Neurologic - ie. spinal cord injuries, spina bifida, and CVAs 

  • Non-neurologic

    • Most common in women are non-neurologic, usually after OASIS, may occur even remote from delivery 

    • Medications can also cause

Why do we care? 

  • Effect on quality of life

    • Significant effect 

    • Can cause depression, social isolation, shame, embarrassment, etc 

    • Can also worsen sexual function 

How do we evaluate? 

  • Screen!

    • ACOG says women with risk factors should be screened because they are often reluctant to disclose  

    • Should ask in women with other pelvic floor disorders 

    • Other risk factors that can be considered: Age >50, residence in nursing home, prior OASIS, history of pelvic irradiation, engagement in anal intercourse, presence of urinary incontinence, chronic diarrhea, diabetes, obesity, rectal urgency 

  • History and physical 

    • Ask about underlying neurological disorders and also modifiable risk factors for fecal incontinence (ie. obesity, diabetes, smoking, anal sex, certain medications that cause loose stools) 

    • Symptoms: what type of leakage (solid, liquid, gas, mucus), timing, frequency, severity (volume of loss), if there is fecal urgency, and how this affects their life 

    • There are a few validated surveys 

      • FI Severity Index, FI Quality of Life Scale, Fecal incontinence and Constipation Assessment Questionnaire 

    • Physical exam should include vaginal exam, exam of perineal area, and rectal exam (prior anal sphincter surgery/trauma) 

      • “Dovetail” sign - loss of normal puckering around the anus anteriorly

      • Digital rectal exam - sensitivity and specificity is overall low for detection of complete anal sphincter disruption 

      • Can also consider endoanal ultrasonography 

  • Other tests

    • Anal sphincter imaging/defecography/anorectal manometry not recommended for routine evaluation 

    • However, if anatomic defect or dysfunction is suspected or if clinical exam findings are inconclusive, can refer for ancillary testing 

    • Can also consider referring to urogynecology/colorectal surgery for further evaluation if not sure in clinic 

How do we manage and treat FI? 

  • Medical

    • Should be multidisciplinary approach 

      • Consider pelvic floor PT and management with urogynecology 

      • Also can consider gastroenterology

    • Medications

      • While loose stool itself does not cause fecal incontinence, it can worsen it and be a risk factor

        • Try something to bulk up stool - ie. fiber supplementation, dietary manipulation, bowel scheduling, etc 

      • Lifestyle management - should be offered in conjunction with everything else 

        • Wearing pads, diapers, briefs, etc 

        • Anal plugs ← 51% of people reported some sort of adverse event, like urgency, irritation, pain, soreness.

    • How effective are non-surgical treatments? 

      • Associated with modest short-term efficacy and low risk of adverse events, so should be recommended for initial management unless there is a fistula or rectal prolapse on exam 

      • However, lacking evidence for effectiveness of treatment beyond 6 months 

  • Surgical

    • Anal Sphincter Bulking Agents - not really surgery, kind of in between? 

      • Include things like dextranomer in stabilized hyaluronic acid, silicon biomaterial, carbon-coated beads 

      • May be effective in decreasing FI episodes up to 6 months 

    • Who is eligible for surgeries?

      • Not first line except for the two indications mentioned above (fistula or prolapse)

      • Proven to only provide short term improvement and have more complications than medical treatments/lifestyle modifications 

      • If patients fail medical treatments → can have surgery 

      • Refer to urogynecologist or qualified specialist to do them  

    • Neuromodulation 

      • Sacral nerve stimulation is possible for ABL 

        • Implantation of wire electrode near third sacral nerve root 

        • Two step → if initial testing is beneficial, then permanent battery is attached to wire electrode 

        • 2013 systemic review: 63% success rate (50% or greater reduction of FI) in the short term (<1 year), 58% in medium term (17-36 months), 54% (44-118 months)

      • Peripheral tibial nerve stimulation is not approved for FI 

    • Anal Sphincter Repair 

      • Sphincteroplasty can be considered with anal sphincter disruption and fecal incontinence symptoms who have failed conservative treatment 

      • Can do it end to end or overlapping sphincteroplasty 

      • Most studies:

        • Found to have similar outcomes 

        • Some evidence has shown that there can be significant deterioration in fecal incontinence over time after either type of repair, with 50% of women reporting symptoms 5-10 years after their repair

      • Most common adverse effect is wound infection (6-35% of cases!!) 

    • Other surgeries can be considered:

      • Radiofrequency anal sphincter remodeling 

      • Gracilis muscle transposition 

      • Diverting colostomy  

Female Sexual Dysfunction

/

What is normal sexual response? 

  • Original landmark studies had a very linear model of “normal sexual response” 

    • Excitement → plateau → orgasm → resolution 

  • More contemporary model is non-linear and encompasses a variety of sequences of the original four stages of as well as other stages 

    • Estrogen plays a significant role in female sexual response, including maintenance of genital tissue sensitivity, elasticity, secretions, pH, etc, as well as urinary continence, pelvic floor muscle tone, and joint mobility 

    • Approximately 43% of American women report experiencing sexual problems, with higher prevalence in women aged 45-64

What are the different types of sexual dysfunction? 

Based on the DSM-V - 5 specific types of female sexual dysfunction:

  • Female sexual interest and arousal disorder 

    • Lack of or significant decrease in at least three of the following: 

      • Interest in sexual activity 

      • Sexual or erotic thoughts or fantasies 

      • Initiation of sexual activity and responsiveness to a partner’s initiation 

      • Excitement or pleasure during all or almost all sexual activity

      • Interest or arousal in response to internal or external sexual erotic cues 

      • Genital or nongenital sensations during sexual activity in almost all or all sexuall encounters 

    • Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals 

  • Female orgasmic disorder 

    • Marked delay in, marked infrequency of, or absence of orgasm, or markedly reduced intensity of orgamsic sensations in almost all or all occasions of sexual activity 

    • Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals  

  • Genito-pelvic pain/penetration disorder 

    • The persistent or recurrent presence of one or more of the following symptoms:

      •  Difficulty having intercourse 

      • Marked vulvovaginal or pelvic pain during intercouruse or penetration attempts 

      • Marked fear or anxiety about vulvovaginal or pelvic pain anticipating, during, or resulting from vaginal penetration 

    • Symptoms have persisted for a minimum of 6 months and cause clinically significant distress in individuals  

  • Substance/medication-induced sexual dysfunction 

    • Disturbance in sexual function that has a temporal relationship with substance/ medication initiation, dose increase, or discontinuation and causes clinically significant distress in the individual 

  • Other specified or unspecified sexual dysfunction

    • Distressing symptoms characteristic of sexual dysfunction that do not meet the criteria of one of the defined categories. The major distinction between specified and unspecified is whether the clinician specifies reason that the symptoms do not meet criteria for other classes 

    • One specified reason: genitourinary syndrome due to menopause 

How should we evaluate for FSD? 

  • Ask about it!

    • During routine visits, can ask questions about sexual function 

    • Ask broad, open-ended questions during routine history gathering 

    • “Many women experience concerns about sex. Are you experiencing any issues?” 

  • Initial approach if patient answers yes, or if FSD is a complaint 

    • Comprehensive History 

      • Should ask detailed history about patient’s sexual and gender identity 

      • Nature, duration, and onset of symptoms - also if symptoms cause distress 

      • If patient is using medications 

      • Partner factors (ie. number of current partners, their gender, health problems, sexual function problems) 

      • Relationship quality - communication about sexual concerns with partner, past and current abuse or violence experience

      • Pain/injuries/Body image 

    • Physical Exam

      • Often, there are not specific physical exam findings 

      • However, use of mirror and pointing out female anatomy for education is sometimes helpful 

      • Can also identify if there are areas that are causing pain 

How do we treat FSD? 

  • Psychological Interventions 

    • Relationship distress and partner sexual dysfunction can trigger sexual problems in other domains 

    • Options include sexual skills training, cognitive-behavioral therapy, mindfulness-based therapy, and couples therapy 

      • Sexual skills training: can include instructions in masturbation, other erotic stimulation, decrease feelings of guilt and shame with masturbation, as well as learning about anatomy (ie. clitoral stimulation)

      • Couples therapy: exercises to better communication with partner 

      • History of trauma - may need trauma-based psychotherapeutic approach  

    • Can consult or refer to mental health specialists with expertise in this area 

  • Medical therapy

    • Estrogen

      • Low-dose vaginal estrogen therapy is the preferred hormonal treatment for FSD due to genitourinary syndrome of menopause  

      • Low-dose systemic estrogen can be an alternative 

      • Other alternatives include Ospemifene for management of dyspareunia due to genitourinary syndrome of menopause 

    • Androgen Therapy

      • Short-term use of transdermal testosterone can be considered for treatment of postmenopausal women with sexual interest andd arousal disorders 

      • Need to appropriately counsel that there are risks (ie. acne, increased hair growth, virilization - may be irreversible) and long-term side effects are not known 

      • Can try for 3-6 months after baseline testosterone is tested and after 3-6 weeks of initial use 

      • Should be discontinued if no effect after 6 months 

    • Flibanserin 

      • Addyi on the market 

      • Serotonin receptor agonist/antagonist and was approved in 2015 by the FDA to treat hypoactive sexual desire disorder in premenopausal women without depression 

      • However, systematic review and meta-analysis of existing studies showed that overall quality of evidence for efficacy and safety were low, and there was minimal to no improvement in hypoactive sexual desire disorder with use 

      • Black box warning against alcohol use - increased risk of syncope and hypotension 

    • Sildenafil (Viagra) 

      • Not efficacious

      • Hypothesized that it may increase pelvic blood flow to clitoris and vagina, but has not been proven to work 

    •  Bupropion 

      • If patient has antidepressant-induced female sexual dysfunction, supplementation with bupropion may improve symptoms 

  •  Other 

    • For genito-pelvic pain and penetration disorders:

      • Education to help patient understand anatomy and etiology of their symptoms 

      • Vaginal dilators

      • Physical therapy (Pelvic PT) 

      • Intravaginal prasterone for treatment of postmenopausal women who have dyspareunia 

      • Lubricants and moisturizers 

        • Don’t cure the underlying cause, but may reduce or alleviate dyspareunia that is due to vaginal dryness 

          • Coconut oil is a good option, but do not use with condoms 

          • Tend to counsel more toward silicone-based lubricants because they do not dry out as quickly as water-based lubricants 

      • Vaginal lasers

        • Became a hot topic while we were senior residents and some people raved about them; latest evidence suggesting they’re not effective.

        • Vaginal CO2 fractional laser is inadequately studied for treatment of vulvovaginal atrophy 

        • Cost of treatment is rather high 

Prenatal Genetic Screening: An Update

/

One of our very first podcasts covered prenatal genetic screening and testing. Since then, ACOG has updated the former PB 163 to the new PB 226. For today, we’ll cover some changes/updates and get more into diagnostic testing, which we didn’t cover in depth on our previous episode. Diagnostic testing info remains well-covered by PB 162.

How do you provide genetic counseling to a patient? 

  • Every pregnancy has a risk for genetic abnormality and review that this risk increases with increasing age

    • Average rate is 1/150 live births. There is also risk based on family history. 

      • Review family history of birth defects, genetic diagnoses in the family, etc. prior to discussion

    •  Risk of abnormalities based on age:

  • Review options for genetic screening for patients.

    • All types of genetic screening is limited, and all genetic screening tests detect fewer abnormalities than diagnostic tests with microarray. Diagnostic tests include CVS and amniocentesis.

  • Screening and diagnostic testing should be discussed and offered to all patients early in pregnancy regardless of maternal age or baseline risk

What are the available tests?

  • Preimplantation genetic testing/screening 

    • PGT-A (also called PGS previously) - preimplantation genetic testing for aneuploidies 

      • Biopsy of an embryo at the blastocyst stage, usually around day 5-6 of development 

      • Cells are taken from the outer layer of cells (trophectoderm) that will eventually become the placenta 

      • PGT-A just screens for aneuploidy, and the idea is to increase the chances of live birth by screening for embryos that have aneuploidy.

    • PGT-M - preimplantation genetic testing for monogenetic/single gene mutations

      • Same as above in terms of how the cells are gotten, but in this case, tests are done for monogenic disease or single gene mutations 

      • Can be used to choose embryos that do not have a genetic disease, like screening for embryos that do not have Huntington’s or cystic fibrosis 

      • Disease and mutation must be known beforehand — this is a highly targeted screening.

    • PGT-SR - preimplantation genetic testing for structural rearrangements 

      • Useful when there are parental structural chromosomal abnormalities.

      • Detects things like translocation, inversion, deletions, insertions, etc.

    • With PGT, because the cells biopsied are destined to become placenta, other forms of pregnancy genetic screening should still be offered due to risk of mosiacism - that is, different genetic material in different cell lines.

  • Screening and Testing During Pregnancy 

    • Discuss that many screening tests are sensitive for T21, but may have less sensitivity for other chromosomal disorders. 

    • Review these tests cannot detect other genetic abnormalities like point mutations, deletions, translocations, etc. 

    • Types of screening tests: 

      • NIPT (cell free DNA) – test any time around 9-10 weeks to term. 99% detection rate for trisomy 21. It has the highest DR of all tests and lowest false positive rate, but also may detect maternal aneuploidy or disease. Highest sensitivity and specificity. Does NOT test for open neural tube defects.

        • Someone with a screen positive serum analyte test may choose cfDNA for follow up if they want to avoid a diagnostic test, but they should be informed that it is still a screening test, meaning it can still fail to identify some chromosomal abnormalities and may delay definitive testing if positive.

      • Integrated screen – two tests. First is at 10w-13w6d. Then 15-22w. DR for T21 is 96%, but you need two samples and no first trimester results. Method: NT + PAPP-A in first trimester, then quad screen (hCG, AFP, uE3, inhibin A)

      • Sequential – 10w-13w6d, then 15-22 w. 95% DR for T21. Still need two samples, with first trimester NT + BHCG, PAPP-A and +/- AFP. Then quad screen.

      • Quad screen – 15w-22w. 81% DR for T21. It’s a one-time test, but also has lower DR than integrated

      • Other options with lower detection rates: first trimester screen (NT+PAPP-A, bHCG, AFP), Serum integrated (Integrated just without NT), NT alone

ACOG PB 226

Diagnostic Testing

  • The gold standard for detecting genetic abnormalities and should be offered after abnormal genetic screening tests.

  • Chorionic villi sampling – done between 10-13 weeks. 

    • Get placental villi transabdominally or transcervically. 

    • Pregnancy loss rate 1/500. Limb reduction defect is super low, around 6/10,000. 

    • Can cause spotting/bleeding. Also the tissue is placental, so there is still possibility of mosaicism (ie. placenta doesn’t have abnormalities, but fetus does). 

      • Because of this, sometimes after CVS can still recommend amnio.

  • Amniocentesis – done between 15-20 weeks usually, but can be done any time later too. 

    • Reason not to do too early: amnion and chorion not fused, increasing anomalies/loss rate.

    • Rate of loss is about 1:300 – 1:750 depending on studies. 

    • Other complications include spotting or loss of fluid. 

    • Cells are from sloughed off fetal skin cells, so can actually get fetal DNA.

  • Type of tests that can be sent from diagnostic testing - a question you might get: what are you sending it for? 

    • Karyotype

      • Detects aneuploidies, like trisomies, 45X, 47 XXY.

      • Need culturable cells, so takes longer (7-10 days).

      • Cannot usually be done on dead tissue (ie. stillbirth), because the cells likely won’t grow 

    • Microarray

      • Can find major aneuploidies and submicroscopic changes that you can’t see just with karyotype.

      • Can’t detect balanced translocations and triploidy.

      • Can be done on cultured cells or uncultured tissue.

      • Can also be done on copy number variants If done on uncultured cells.

      • Can be fast turn-around (3-7 days).

    • FISH

      • Uses probes for specific chromosomes or chromosomal regions (ie, can detect T21 but also can detect 22q11.2 deletion).

      • Can be done on uncultured cells, so can get results in as few as 2 days.

      • Good to use if someone screens positive for T21 or other aneuploidy on serum analytes or cfDNA and you want a quick results before you get the full karyotype/microarray results

      • Often start with FISH, then reflex to microarray if normal, or karyotype if abnormal (to confirm).

Tobacco Use in Pregnancy

/

Tobacco remains the leading cause of preventable disease, disability, and death in the USA, despite overall decreasing rates of smoking!

  • 14% of US adults smoke cigarettes. This rate is lower in pregnancy, around 7.2%; however, young women are a high risk group for cigarette smoking compared to the general population.

  • Tobacco use in pregnancy specifically is linked to higher risk of:

    • Ectopic pregnancies

    • Cleft lip/palate

    • Fetal growth restriction and low birth weight (13-19% of term infants with tobacco exposures)

    • Placenta previa

    • Placental abruption

    • PPROM

    • Preterm delivery (5-8% attributable risk)

    • Increased perinatal mortality (5-7% attributable risk)

    • Increased risk of sudden infant death syndrome (22-34% attributable risk)

  • Tobacco use also has lifelong health implications!

    • Pregnancy can be a great motivator to quit smoking and make significant changes for lifelong health -- 54% of those who smoke during/pre-pregnancy will quit at least for pregnancy!

  • Data regarding e-cigarettes/vaping, cigars, and hookah are limited, though are also risky.

    • However, these may have somewhat different risks, though many (particularly hookah and vaping) are perceived to be safer -- they are not!

    • The CO 807 has a great table comparing amounts of nicotine in each varying method of consumption -- worth keeping handy when you’re looking to prescribe/suggest replacement therapy:

ACOG CO 807

How do I intervene as a clinician?

  • Ask!

    • Be sure to ask about alternative forms of nicotine consumption as well -- patients may not disclose vaping/hookah/etc. Use unless specifically asked. 

  • Use motivational interviewing techniques

    • Cognitive behavioral therapy and motivational interviewing are beneficial to initiate and sustain tobacco use cessation.

    • Even if not ready to quit, consistent motivational approaches may be beneficial over time.

  • You can use a tool, like the 5As:

    • Ask -- characterizing use at the same time

    • Advise -- if still using, provide advice about risks of continued use

    • Assess -- whether patient is willing to quit. This can be continued with motivational strategy at future visits if not ready at the first.

    • Assist -- if ready to quit, provide materials and options to help get the quit started. Suggest importance of having a tobacco-free space at home, seeking out a “quitting buddy,” and/or using a service like 1-800-QUIT-NOW to provide ongoing support.

    • Arrange -- continue follow up visits to track/encourage success 

  • 50-60% of those who quit smoking during pregnancy will resume within 1 year postpartum.

    • Keep up and continue to ask at future visits.

    • Encourage whole family to quit smoking as well to have family-motivated success.

Pharmacotherapy for tobacco cessation

  • If used during pregnancy, note data is limited for most methods. 

  • Nicotine replacement:

    • Provide a stable, controlled dose of nicotine in the form of gums, patches, or lozenges

      • Gums may provide some benefit psychologically due to oral fixation

    • Have not been demonstrated to be effective in pregnancy, unfortunately.

      • Any planned use should be with clear resolve of patient to quit in mind, as these methods still deliberately expose maternal-fetal dyad to nicotine and likely some continued form of risk.

  • Pharmacologic cessation agents

    • Varencicline (Chantix)

      • Dose pack to start therapy.

      • Partial agonist for nicotinic receptors in brain

      • Limited data in pregnancy, but that which exists does not demonstrate teratogenicity.

    • Bupropion (Wellbutrin)

      • Most studies have looked at a dose of 150mg BID for 7-12 weeks.

      • Antidepressant

      • Also limited data in pregnancy, but no known risk of fetal anomalies or adverse pregnancy outcomes.