What's new in...family planning
Managing alcohol abuse in pregnancy
Kerry is a 31-year-old financial consultant in her first pregnancy. She sees you at 9:30 in your morning surgery. A waft of alcohol follows her into your consulting room. Kerry is 22 weeks' pregnant and feeling tired. She feels she has little sympathy from her boss he expects her to work long hours like the other employees. You ask about her drinking habits but she denies excessive intake. Kerry asks you to write a private sicknote for a week to help her get over the tiredness.
Dr Tanvir Jamil discusses.
Not many young women smell of alcohol first thing in the morning. It is certainly a worrying sign. Don't forget the CAGE questionnaire, but the AUDIT-C has been recently recommended.
·How often do you have a drink containing alcohol?
·How many drinks do you have on a typical day when you are drinking?
·How often do you have six drinks or more on one occasion?
(Maximum score 12, cut-off for possible heavy drinking five.)
I know too much alcohol in pregnancy can cause fetal alcohol syndrome (FAS) but is this pretty rare?
Many of us have probably only come across FAS during our paediatric attachments. Remember that FAS is characterised by:
·Abnormal facial features and microcephaly
·Central nervous system abnormalities (mental retardation and developmental delay)
New evidence seems to indicate doctors have only been recognising severe cases of FAS while children less severely affected are often labelled as having 'behavioural problems.' Up to one in 100 children may be affected. Consider FAS in any child who has a combination of the following: small for their age, snubb nose, thin upper lip, poor co-ordination, hyperactive, small eyes, learning disabilities and language and speech delay. Children with FAS may well increase as figures show that more young women than ever are binge drinking. Alcohol-related neurodevelopmental disorders (ARND) is a relatively new term for a 'mild form' of FAS.
So how much alcohol is too much in pregnancy?.
Many doctors think a few units a week is safe. In fact Alcohol Concern and the Royal College of Midwives state that up to three units/week are safe in pregnancy. But there are many experts who feel even a small amount of alcohol can harm the unborn child.
They feel all women should be asked about alcohol intake at the first antenatal consultation and in fact, like smoking, it should be part of preconceptual counselling. At present no one can quite agree as to how much is actually safe in pregnancy but everyone agrees that alcohol crosses the placenta into the fetus.
So how can I help Kerry?
Kerry is under a great deal of pressure from her employer and being pregnant and tired is not helping. But other factors may also play a part: has she had alcohol problems in the past? Is there a history of alcoholism in the family? Could she be depressed? Are there other stressors in her life apart from the job?
It may be worth giving in to her request for a sicknote as long as she agrees to come back and see you for review. You will need to explain the effects of alcohol on her unborn child and this may be the motivation she needs to stop drinking altogether.
Women who drink excessive alcohol during pregnancy are also more at risk of spontaneous abortion or stillbirth. A recent study has also found women who binge drink, get depressed or smoke during pregnancy boost their risk of depression and alcohol use after they give birth as well. Remember the motivational interviewing strategies for alcohol-related problems:
·Precontemplation feedback on assessment of current levels of drinking; discuss associated risks; discuss lifestyle/ stresses and how alcohol fits in.
·Contemplation 'What are some good and less good things about your use of alcohol'; explore reasons to quit and reasons to continue drinking; other information on health effects of drinking; recommend cutting back/stopping and explore options for taking action.
·Action encourage commitment to action; address her concern's about changing behaviour; consider referral to treatment programmes or a mutual aid group counsellor, eg Alcoholics Anonymous (AA).
·Maintenance foster confidence in her ability to sustain change; help develop a plan to prevent relapse; continue with AA.
·Relapse explore reasons for relapse; encourage the belief that relapse does not mean failure; consider alternative treatments or coping strategies.
Kerry has a much greater chance of coming off the alcohol if she has a good support network in place. So ask her about her partner, friends and relatives. Perhaps one of them could come with her to the next review. Your support will also be invaluable and giving her appropriate sympathy and time with regular follow-up will help.
Are there any investigations that need to be done?
It is worth requesting liver function tests and a full blood count. Specifically you are looking for a raised GGT and MCV. These baseline figures can also be used for follow-up monitoring. Look also at AST and ALT (ratio of 2:1 in alcoholics). Lastly look for anaemia and thrombocytopenia which can also be caused by excessive alcohol intake.
What other practical advice can I give Kerry?
Simple advice is often most appropriate: You do not have to drink when your colleagues have a drink; If someone gives you a drink it's OK to say no; Stay away from people or places that make you drink; Do not keep alcohol at home. Reassure Kerry that it is never too late to stop drinking in pregnancy.
Tanvir Jamil is on sabbatical in Canada