Segmental hair analysis to assess effectiveness of single-session motivational intervention to stop ethanol use during pregnancy

Psychosocial and medication interventions to stop or reduce alcohol consumption during pregnancy

BACKGROUND

Despite the known harms, alcohol consumption is common in pregnancy. Rates vary between countries, and are estimated to be 10% globally, with up to 25% in Europe.

OBJECTIVES

To assess the efficacy of psychosocial interventions and medications to reduce or stop alcohol consumption during pregnancy.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO, from inception to 8 January 2024. We also searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). All searches included non-English language literature. We handsearched references of topic-related systematic reviews and included studies.

SELECTION CRITERIA

We included randomised controlled trials that compared medications or psychosocial interventions, or both, to placebo, no intervention, usual care, or other medications or psychosocial interventions used to reduce or stop alcohol use during pregnancy. Our primary outcomes of interest were abstinence from alcohol, reduction in alcohol consumption, retention in treatment, and women with any adverse event.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included eight studies (1369 participants) in which pregnant women received an intervention to stop or reduce alcohol use during pregnancy. In one study, almost half of participants had a current diagnosis of alcohol use disorder (AUD); in another study, 40% of participants had a lifetime diagnosis of AUD. Six studies took place in the USA, one in Spain, and one in the Netherlands. All included studies evaluated the efficacy of psychosocial interventions; we did not find any study that evaluated the efficacy of medications for the treatment of AUD during pregnancy. Psychosocial interventions were mainly brief interventions ranging from a single session of 10 to 60 minutes to five sessions of 10 minutes each. Pregnant women received the psychosocial intervention approximately at the end of the first trimester of pregnancy, and the outcome of alcohol use was reassessed 8 to 24 weeks after the psychosocial intervention. Women in the control group received treatment as usual (TAU) or similar treatments such as comprehensive assessment of alcohol use and advice to stop drinking during pregnancy. Globally, we found that, compared to TAU, psychosocial interventions may increase the rate of continuously abstinent participants (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.14 to 1.57; I2 =0%; 3 studies; 378 women; low certainty evidence). Psychosocial interventions may have little to no effect on the number of drinks per day, but the evidence is very uncertain (mean difference -0.42, 95% CI -1.13 to 0.28; I2 = 86%; 2 studies; 157 women; very low certainty evidence). Psychosocial interventions probably have little to no effect on the number of women who completed treatment (RR 0.98, 95% CI 0.94 to 1.02; I2 = 0%; 7 studies; 1283 women; moderate certainty evidence). None of the included studies assessed adverse events of treatments. We downgraded the certainty of the evidence due to risk of bias and imprecision of the estimates.

AUTHORS' CONCLUSIONS

Brief psychosocial interventions may increase the rate of continuous abstinence among pregnant women who report alcohol use during pregnancy. Further studies should be conducted to investigate the efficacy and safety of psychosocial interventions and other treatments (e.g. medications) for women with AUD. These studies should provide detailed information on alcohol use before and during pregnancy using consistent measures such as the number of drinks per drinking day. When heterogeneous populations are recruited, more detailed information on alcohol use during pregnancy should be provided to allow future systematic reviews to be conducted. Other important information that would enhance the usefulness of these studies would be the presence of other comorbid conditions such as anxiety, mood disorders, and the use of other psychoactive substances.

Assessment of alcohol consumption in mexican pregnant women by hair testing of ethyl glucuronide

There are no studies that have utilized both biomarkers and self-reported data to evaluate maternal alcohol use during pregnancy in Mexico. Therefore, we aimed to describe the prevalence of alcohol consumption in a cohort of 300 Mexican pregnant women. We used a validated ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to measure hair ethyl glucuronide (EtG) in hair segments that corresponded to the first and second half of pregnancy. We compared the hair EtG values to a self-reported questionnaire on maternal drinking habits and evaluated whether the gestational alcohol use was associated with psychotropic drug use. Based on the EtG measurements, 263 women (87.7%) were alcohol-abstinent during the entire pregnancy, while 37 (12.3%) had used alcohol at least once during the pregnancy. Of these, only two women were found to have problematic alcoholic behavior during the entire pregnancy. No significant differences in sociodemographic characteristics were observed between alcohol-abstinent women and women with drinking habits. The self-reporting data and hair EtG gave heterogeneous results: although 37 women had self-reported alcohol use during pregnancy, only 54.1% of these women tested positive for hair EtG. Of the women who tested positive for hair EtG, 54.1% tested positive for psychoactive substances. In our cohort, the use of drugs of abuse was independent of gestational drinking. This study provided the first objective evidence of prenatal ethanol consumption in a cohort of Mexican pregnant women.

The Impact of Alcohol Consumption and Oral Microbiota on Upper Aerodigestive Tract Carcinomas: A Pilot Study

Alcohol consumption is associated with oxidative stress and an increased risk of carcinoma of the upper aero-digestive tract (UADT). Recently, it has been found that some microorganisms in the human oral cavity may locally metabolize ethanol, forming acetaldehyde, a carcinogenic metabolite of alcohol. In a cohort of patients first visited for UADT cancers, we estimated their alcohol consumption by measuring Ethyl Glucuronide/EtG (a long-lasting metabolite of ethanol) in the hair and carbohydrate-deficient transferrin/CDT (short-term index of alcohol intake) in the serum. Moreover, we analyzed, by culture-based methods, the presence of Neisseria subflava, Streptococcus mitis, Candida albicans, and glabrata (microorganisms generating acetaldehyde) in the oral cavity. According to the EtG values, we correlated drinking alcohol with endogenous oxidative stress and the investigated microorganism's presence. We found that 55% of heavy drinkers presented microorganisms generating acetaldehyde locally. Moreover, we found that the presence of oral acetaldehyde-producing bacteria correlates with increased oxidative stress compared to patients without such bacteria. As for the study of alcohol dehydrogenase gene polymorphisms (the enzyme that transforms alcohol to acetaldehyde), we found that only the "CGTCGTCCC" haplotype was more frequent in the general population than in carcinoma patients. This pilot study suggests the importance of estimating alcohol consumption (EtG), the presence of bacteria producing acetaldehyde, and oxidative stress as risk factors for the onset of oral carcinomas.

Effectiveness of brief alcohol interventions for pregnant women: a systematic literature review and meta-analysis

BACKGROUND

Prenatal alcohol exposure (PAE) can result in a range of adverse neonatal outcomes, including Fetal Alcohol Spectrum Disorder (FASD). This systematic review and meta-analysis sought to investigate the effectiveness of brief interventions (BIs) in eliminating or reducing 1) alcohol consumption during pregnancy; and 2) PAE-related adverse neonatal outcomes; and 3) cost-effectiveness of BIs.

METHOD

We conducted a systematic literature search for original controlled studies (randomized control trials (RCTs); quasi-experimental) in any setting, published from 1987 to 2021. The comparison group was no/minimal intervention, where a measure of alcohol consumption was reported. Studies were critically appraised using the Centre for Evidence-based Medicine Oxford critical appraisal tool for RCTs (1). The certainty in the evidence for each outcome was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) (2). Meta-analysis of continuous and binary estimates of effect-size for similar outcome measures for BIs versus control groups were pooled and reported as mean difference (MD) Hedges' g and odds ratios (ORs), respectively.

RESULTS

In total, 26 studies, all from high income countries, met inclusion criteria. Alcohol abstinence outcome available in 12 studies (n = 2620) found modest effects in favor of BIs conditions by increasing the odds of abstinence by 56% (OR = 1.56, 95% confidence interval (CI) = 1.15-2.13, I² = 46.75%; p = 0.04). BIs effects for reduction in mean drinks/week (Cohen's d = - 0.21, 95%CI = - 0.78 to 0.36; p = 0.08) and AUDIT scores (g = 0.10, 95%CI = - 0.06 to 0.26; p = 0.17) were not statistically significant. Among seven studies (n = 740) reporting neonatal outcomes, BI receipt was associated with a modest and significant reduction in preterm birth (OR = 0.67, 95% CI = 0.46-0.98, I² = 0.00%; p = 0.58). No statistically significant differences were observed for mean birthweight or lower likelihood of low birth weight (LBW). Certainty in the evidence was rated as 'low'. No eligible studies were found on cost-effectiveness of BIs.

CONCLUSION

BIs are moderately effective in increasing abstinence during pregnancy and preventing preterm birth. More studies on the effectiveness of BIs are needed from low- and middle-income countries, as well as with younger mothers and with a broader range of ethnic groups.

Effective psychological therapies to improve lifestyle behaviors in (pre)pregnant women: A systematic review

Poor lifestyle behaviors impact (pre)pregnant women by affecting pregnancy outcomes and offspring health. This systematic review provides an overview of psychological therapies to support lifestyle behavior changes among (pre)pregnant women. Scientific databases were searched from their inception to 20 December 2020 for studies investigating the effects of psychological therapies on improvements in lifestyle behaviors. Studies were eligible if they included (pre)pregnant women, examined the effects of a psychological therapy on at least one lifestyle behavior and used a control group receiving usual pregnancy care or a non-psychological intervention. Lifestyle behaviors of interest were dietary intake, physical activity, smoking, alcohol consumption, drug use, body weight loss and body weight gain during pregnancy. Pregnancy complications were included as outcome measures. Motivational interviewing (MI) (n = 21), cognitive behavioral therapy (CBT) (n = 8), incentive-based contingency management (IBCM) (n = 9), mindfulness (n = 1) and hypnosis (n = 1) were investigated as lifestyle behavior interventions. The findings revealed that MI was effective in reducing (self-reported) smoking and alcohol consumption and restricting gestational weight gain (GWG). CBT was only studied as an intervention to restrict GWG and the results predominantly confirmed its effectiveness. IBCM showed the strongest effect on reducing smoking and substance use. The studies using hypnosis or mindfulness to reduce smoking or restrict GWG, respectively, showed no associations. The use of psychological therapies to improve lifestyle behaviors among (pre)pregnant women is new and the scientific proof is promising. Before wide implementation is legitimated, more evidence is needed on the consequences of lifestyle change for pregnancy outcomes.

Are psychosocial interventions effective in reducing alcohol consumption during pregnancy and motherhood? A systematic review and meta-analysis

BACKGROUND AND AIMS

Alcohol use by pregnant and parenting women can have serious and long-lasting consequences for both the mother and offspring. We reviewed the evidence for psychosocial interventions to reduce maternal drinking.

DESIGN

Literature searches of PsycINFO, PubMed and Scopus identified randomised controlled trials of interventions with an aim of reduced drinking or abstinence in mothers or pregnant women.

SETTING

Interventions were delivered in healthcare settings and homes.

PARTICIPANTS

Pregnant women and mothers with dependent children.

INTERVENTIONS

Psychosocial interventions were compared with usual care or no intervention.

MEASUREMENTS

The revised Cochrane risk-of-bias tool for randomised trials was used for quality assessments. Narrative synthesis summarised the findings of the studies with a subset of trials eligible for random-effects meta-analysis. General and alcohol-specific behaviour change techniques (BCTs) were identified to investigate potential mechanism of change.

RESULTS

Twenty-four studies were included (20 pregnancy, four motherhood). Because of quality of reporting, data from only six pregnancy and four motherhood studies could be pooled. A significant treatment effect was revealed by the meta-analyses of pregnancy studies regarding abstinence (OR = 2.31, 95% CI = 1.61, 3.32; P < 0.001) and motherhood studies regarding a reduction in drinking (standardised mean difference [SMD] = -0.20, 95% CI = -0.38, -0.02; P = 0.03). Narrative synthesis of the remaining trials yielded inconsistent results regarding intervention effectiveness. A wide range of BCTs were used, present in both effective and ineffective interventions. The most commonly used general and alcohol-specific BCTs included information about consequences, social support, goal setting and action planning.

CONCLUSIONS

In pregnant women identified as consuming alcohol, psychosocial interventions appear to increase abstinence rates compared with usual care or no intervention. Similarly, such interventions appear to lead to a reduction in alcohol consumption in mothers with dependent children. It is unclear that behaviour change techniques are contributing to these effects. Conclusions from randomised controlled trials are only meaningful if the behavioural outcome, population, setting, intervention and comparator are clearly reported. An important barrier when it comes to identifying effective behaviour change techniques is a widespread failure to provide enough information in study reports.

The Distribution of Available Prevention and Management Interventions for Fetal Alcohol Spectrum Disorder (2007 to 2017): Implications for Collaborative Actions

The global prevalence of Fetal Alcohol Spectrum Disorder (FASD) remains high despite the various preventive and management interventions that have been designed and implemented to tackle the issue in various settings. The aim of the scoping review is to identify and classify prevention and management interventions of FASD reported globally across the life span and to map the concentration of these interventions across the globe. We searched some selected databases with predefined terms. Framework and narrative approaches were used to synthesize and report on the findings. Thirty-two prevention intervention studies and 41 management interventions studies were identified. All the interventions were reported to be effective or showed promising outcomes for the prevention and management of FASD, except four. Although Europe and Africa have a relatively higher prevalence of FASD, the lowest number of interventions to address FASD were identified in these regions. Most of the interventions for FASD were reported in North America with comparatively lower FASD prevalence. The uneven distribution of interventions designed for FASD vis-à-vis the burden of FASD in the different regions calls for a concerted effort for knowledge and intervention sharing to enhance the design of contextually sensitive preventive and management policy in the different regions.

WFSBP * and IAWMH ** Guidelines for the treatment of alcohol use disorders in pregnant women

OBJECTIVES

These practice guidelines for the treatment of alcohol use disorders during pregnancy were developed by members of the International Task Force of the World Federation of Societies of Biological Psychiatry and the International Association for Women's Mental Health.

METHODS

We performed a systematic review of all available publications and extracted data from national and international guidelines. The Task Force evaluated the data with respect to the strength of evidence for the efficacy and safety of each medication.

RESULTS AND DISCUSSION

There is no safe level of alcohol use during pregnancy. Abstinence is recommended. Ideally, women should stop alcohol use when pregnancy is planned and, in any case, as soon as pregnancy is known. Detecting patterns of alcohol maternal drinking should be systematically conducted at first antenatal visit and throughout pregnancy. Brief interventions are recommended in the case of low or moderate risk of alcohol use. Low doses of benzodiazepines, for the shortest duration, may be used to prevent alcohol withdrawal symptoms when high and chronic alcohol intake is stopped and hospitalisation is recommended. Due to the low level of evidence and/or to low benefit/risk ratio, pharmacological treatment for maintenance of abstinence should not be used during pregnancy. At birth, foetal alcohol spectrum disorders must be searched for, and alcohol metabolites should be measured in meconium of neonates in any doubt of foetal alcohol exposure.

Metabolomics of Pregnancy Complications: Emerging Application of Maternal Hair

In recent years, the study of metabolomics has begun to receive increasing international attention, especially as it pertains to medical research. This is due in part to the potential for discovery of new biomarkers in the metabolome and to a new understanding of the "exposome", which refers to the endogenous and exogenous compounds that reflect external exposures. Consequently, metabolomics research into pregnancy-related issues has increased. Biomarkers discovered through metabolomics may shed some light on the etiology of certain pregnancy-related complications and their adverse effects on future maternal health and infant development and improve current clinical management. The discoveries and methods used in these studies will be compiled and summarized within the following paper. A further focus of this paper is the use of hair as a biological sample, which is gaining increasing attention across diverse fields due to its noninvasive sampling method and the metabolome stability. Its significance in exposome studies will be considered in this review, as well as the potential to associate exposures with adverse pregnancy outcomes. Currently, hair has been used in only two metabolomics studies relating to fetal growth restriction (FGR) and gestational diabetes mellitus (GDM).

Development of a Column-Switching HPLC-MS/MS Method and Clinical Application for Determination of Ethyl Glucuronide in Hair in Conjunction with AUDIT for Detecting High-Risk Alcohol Consumption

It is critical to assess the severity of alcohol consumption in certain diseases such as alcohol liver disease and alcohol addiction. Ethyl glucuronide (EtG) is a highly stable metabolite of ethanol in hair; thus, it was proposed as a long-term monitoring marker for alcohol consumption. Therefore, an HPLC-MS/MS method for EtG in hair was developed and applied to a clinical setting to assess the relevance of the EtG concentration and/or the Alcohol Use Disorders Identification Test (AUDIT) score to high-risk alcohol consumption. EtG was extracted from 10 mg of hair using water and analyzed using on-line sample purification coupled to HPLC-MS/MS. The diagnostic performances of the EtG concentration and/or the AUDIT score for detecting high-risk alcohol consumption were statistically evaluated between alcohol addicts (n = 44) and average alcohol users (n = 19). The on-line sample purification resulted in labor-saving with smaller sample amount. Both the EtG concentrations (4.0⁻587.4 pg/mg vs. 12.9⁻74.9 pg/mg) and the AUDIT scores (4⁻40 vs. 5⁻28) obtained from the alcohol addicts were significantly higher than those from the average alcohol users. The performance evaluation demonstrated that the integration score of the EtG concentration and the AUDIT score increased diagnostic performance for high-risk alcohol consumption.

Maternal hair testing to disclose self-misreporting in drinking and smoking behavior during pregnancy

This study aimed to objectively verify smoking and drinking behavior during pregnancy and to disclose self-misreporting through maternal hair analysis. A total of 153 women attending a university hospital in Barcelona (Spain) were selected and interviewed after delivery, on their smoking and drinking habits during pregnancy. A 9-cm hair strand was collected and analyzed by liquid chromatography tandem mass spectrometry for the presence of nicotine (NIC) and ethyl glucuronide (EtG) as biomarkers of tobacco and alcohol consumption, respectively. Concentrations of EtG <7 pg/mg hair and ≥30 pg/mg hair in the 0-3-cm hair segment have been used to assess, respectively, total abstinence and chronic excessive consumption in the previous 3 months, with repetitive moderate drinking lying in the interval 7-30 pg EtG per mg hair. Hair NIC less than 1 ng/mg hair indicates non-exposure to tobacco smoke while hair NIC indicates daily active smoking. In the interview, 28.1% of women declared to have smoked occasionally during gestation, while only 2.6% stated to have consumed alcohol on more than one occasion during pregnancy. Hair testing of smoking biomarkers disclosed that 7.2% of women remained active smokers during the whole pregnancy (hair NIC: 3.21-56.98 ng/mg hair), 16.3% were passive non-smokers or occasional smokers (hair NIC: 1.04-2.99 ng/mg hair), while 76.5% were not exposed to any cigarette smoke (hair NIC < limit of quantification - 0.91 ng/mg hair). Conversely, alcohol hair biomarkers showed that only 35.3% of women were totally abstinent during gestation (hair EtG: 3.89-6.73 pg/mg hair), while 62.7% drank a non-negligible amount of alcohol during pregnancy (hair EtG: 7.06-26.57 pg/mg hair), and 2% were chronic excessive drinkers (hair EtG: 35.33-47.52 pg/mg hair). Maternal hair analysis has shown to be significantly more sensitive than interviews in revealing an alarming misreported prevalence of alcohol use during pregnancy. These findings stress the need to use objective measures to assess alcohol exposure and to consider the inclusion of targeted actions to reduce alcohol consumption in maternal-child health policies.

Biomarkers for the Detection of Prenatal Alcohol Exposure: A Review

Alcohol exposure during pregnancy can cause adverse effects to the fetus, because it interferes with fetal development, leading to later physical and mental impairment. The most common clinical tool to determine fetal alcohol exposure is maternal self-reporting. However, a more objective and useful method is based on the use of biomarkers in biological specimens alone or in combination with maternal self-reporting. This review reports on clinically relevant biomarkers for detection of prenatal alcohol exposure (PAE). A systematic search was performed to ensure a proper overview in existing literature. Studies were selected to give an overview on clinically relevant neonatal and maternal biomarkers. The direct biomarkers fatty acid ethyl esters (FAEEs), ethyl glucuronide (EtG), ethyl sulfate, and phosphatidylethanol (PEth) were found to be the most appropriate biomarkers in relation to detection of PAE. To review each biomarker in a clinical context, we have compared the advantages and disadvantages of each biomarker, in relation to its window of detectability, ease of collection, and the ease and cost of analysis of each biomarker. The biomarkers PEth, FAEEs, and EtG were found to be applicable for detection of even low levels of alcohol exposure. Meconium is an accessible matrix for determination of FAEEs and EtG, and blood an accessible matrix for determination of PEth.