A staged screening strategy for prenatal alcohol exposure and maternal risk stratification

Substance Use During Pregnancy: A Comparative Review of Major Guidelines

Importance

Substance use during pregnancy is a major health issue for both the mother and the fetus, but it also represents an important public health concern.

Objective

The aim of this review was to summarize and compare recommendations from recently published guidelines on substance use during pregnancy and especially regarding alcohol, smoking, and drug use.

Evidence Acquisition

A descriptive review of guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the World Health Organization (WHO), the Society of Obstetricians and Gynaecologists of Canada, and the American College of Obstetricians and Gynecologists on substance use was conducted. Regarding the term "substance use," the most recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition substances were used.

Results

All the reviewed guidelines recommend appropriate counseling and screening women regarding alcohol, smoking, and drug use during the antenatal period, while the management options vary. More specifically, the prompt management of alcohol dependence is emphasized by all the guidelines except from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, which makes no recommendation upon. The use of alcohol during breastfeeding should be avoided. Regarding smoking cessation, all guidelines recommend the use of certain psychosocial, behavioral interventions, and pharmacotherapy. All the guidelines, except the one from the WHO, suggest screening drug users for coexistent sexually transmitted infections. Brief interventions are considered beneficial, while a gradual decrease in benzodiazepines is suggested, as well as the discontinuation of marijuana and methamphetamine use. However, there is controversy regarding breastfeeding in those women as the WHO recommends in favor, whereas the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists recommend against this practice. Finally, all the guidelines state that, following delivery, close monitoring of the neonate is needed.

Conclusions

The diversity of guidelines' recommendations concerning substance use reflects the different ways of the management of pregnant women during routine antenatal care due to absence of strong evidence. More research in the areas of dispute may allow the adoption of an international consensus, in order to early detect and appropriately manage pregnant women with harmful addictions.

The epidemiology of alcohol utilization during pregnancy: an analysis of the Canadian Maternity Experiences Survey (MES)

BACKGROUND

Maternal alcohol consumption during pregnancy may potentially constitute a major public health concern in Canada but despite this, the available epidemiological data on both rates and predictors of alcohol consumption during pregnancy is limited. The present study assessed the prevalence and predictors of maternal alcohol consumption during pregnancy of women living in Canada from 2005-2006 who had a singleton live birth and whose child remained in their care 5-9 months following birth. Prevalence of maternal alcohol consumption was examined across the Canadian provinces.

METHODS

The analysis was based on the Maternity Experience Survey (MES), a population-based survey that assessed pregnancy, delivery and postnatal experiences of mothers and their children between November 2005 and May 2006. The main outcome variable assessed was ever drinking alcohol during pregnancy. The sample of mothers who drank during pregnancy consisted mainly of low to moderate level-alcohol drinkers (95.8%), while only 1.7% of the sample were heavy drinkers (>1 drink per day). Socio-economic factors, demographic factors, maternal characteristics, and pregnancy related factors that proved to be significant at the bivariate level were considered for a logistic regression analysis. Bootstrapping was performed to account for the complex sampling design.

RESULTS

Analysis of 5882 mothers, weighted to represent 72,767 Canadian women, found that 10.8% of women drank alcohol at some point during their pregnancies. This mainly reflects prevalence of low to moderate maternal alcohol consumption. Prevalence of drinking alcohol during pregnancy was 13.8% in Eastern-Central provinces, 7.8% in Western Provinces-British Columbia, 4.1% in Eastern-Atlantic provinces and 4.0% in Western-Prairie Provinces. Utilizing alcohol during gestation was significantly associated with several important factors including marital status, smoking status, reaction to the pregnancy and immigrant status. While being an immigrant to Canada appeared to confer a protective effect, women who have partners (odds ratio (OR)=2.00; 95% confidence interval (CI): 1.20, 3.31) and smoked during pregnancy (OR=1.54; 95% CI: 1.12, 1.87) were significantly more likely to drink alcohol during their pregnancies. Perhaps most importantly, pregnant women who reported indifference or being unhappy/very unhappy in regards to their pregnancies exhibited 1.89- and 2.5-fold increased risk of drinking alcohol during their pregnancies, respectively.

CONCLUSION

A number of important factors associated with maternal alcohol utilization during pregnancy have been identified, indicating areas where increased focus may serve to reduce maternal and pediatric morbidity and mortality.

Diagnosis of fetal alcohol spectrum disorders: a validity study of the fetal alcohol syndrome checklist

Fetal alcohol spectrum disorders (FASD) are a common cause of developmental disability, birth defects, and mortality. The performance characteristics of current diagnostic tools for FASD are not adequately reported. This study examines the performance characteristics of the Fetal Alcohol Syndrome Diagnostic Checklist (FASDC). In a population of 658 subjects from North Dakota, we used the FASDC score to examine the agreement between FASDC score, clinical diagnosis, and the Institute of Medicine criteria for FASD. All subjects were seen for evaluation in the genetic/dysmorphology clinics, which are funded by the state to provide genetic diagnostic services for residents of North Dakota. We compared the clinical diagnosis and the FASDC scores to determine the performance characteristics of the FASDC in the categorical diagnosis of fetal alcohol spectrum (FAS), other-FASD, and a group with No-FASD. Comparisons were made using univariate and logistic models of outcomes using both the presence and the absence of alcohol exposure or FASDC phenotype data. The FASDC performance characteristics for differentiation of the FAS group from non-FASD were excellent (accuracy 99%, sensitivity 99%, and specificity 99%). Logistic models for subjects with scores in the FASD range were differentiated with an accuracy of 82%, sensitivity 85%, and specificity 80% using the data on phenotype and exposure. We were able to delineate subjects with scores in the No-FASD range with an accuracy of 78%, sensitivity 64%, and specificity 81% without including the exposure and phenotype data by use of the other descriptive data (maternal characteristics, birth records, and demographic data) from the FASDC. All diagnostic tools should have performance characteristics assessed and available before adoption for use in clinical settings. The FASDC scores produce diagnostic groupings that approximate expert clinical judgment. The tool may be useful in other clinical settings for the diagnosis of FASD or as an FASD registry or research database.

Do Canadian prenatal record forms integrate evidence-based guidelines for the diagnosis of a FASD?

OBJECTIVES

Prenatal alcohol exposure is a significant public health issue with lifelong psychological, emotional and financial costs associated with caring for an affected individual. In 2005, the Public Health Agency of Canada and Health Canada's First Nations and Inuit Health Branch developed evidence-based guidelines for the diagnosis of a Fetal Alcohol Spectrum Disorder (FASD). We examined the extent to which prenatal records across Canadian provinces and territories currently integrate key recommendations from these guidelines.

METHODS

A content analysis of prenatal record forms retrieved from each Canadian province and territory (N = 12) was conducted to identify all questions or intervention prompts related to prenatal screening, exposure assessment, counseling or referral for maternal alcohol use during pregnancy. Findings were reviewed in relation to recommendations extrapolated from the Canadian guidelines and the FASD literature.

RESULTS

All the prenatal record forms contained questions to assess maternal alcohol use during pregnancy. However, the dimensions of alcohol consumption assessed and the format, wording and number of items related to each dimension varied markedly across provinces/territories. Only five prenatal record forms included a validated screening tool to identify risky alcohol drinking behaviour. Most of the forms lacked prompts to encourage providers to intervene or refer pregnant clients with high-risk drinking behaviour.

CONCLUSION

Integration of the Canadian recommendations into Canadian prenatal record forms may be an effective public health strategy for helping identify pregnancies at high risk for alcohol exposure, reducing the incidence of a FASD through appropriate prenatal intervention and referral, and facilitating early diagnosis of a FASD.

Ethanol and the placenta: A review

OBJECTIVE

In this paper we review published studies of alcohol exposure on placentation, placenta growth and function.

METHODS

We searched PubMed using the MeSH terms: placenta, ethanol, fetal alcohol syndrome and prenatal exposure with delayed effects. We searched the years 1996-2006 and used the references from other articles to expand our search. We limited the search to English only and human only. We excluded studies using choriocarcinoma and animal studies. We grouped the 66 papers into seven topic areas for ease of review.

RESULTS

Alcohol exposure is associated with placental dysfunction, decreased placental size, impaired blood flow and nutrient transport, endocrine changes, increased rates of stillbirth and abruption, umbilical cord vasoconstriction, and low birth weight.

CONCLUSIONS

Prenatal alcohol exposure has a broad range of adverse effects on placental development and function. Additional research on placental development from populations with heavy alcohol exposure should be encouraged. A tissue bank of placentas with detailed assessment of exposure to alcohol, smoking and other relevant data should be considered as a repository to support additional research.

Research-based interventions for children and youth with a Fetal Alcohol Spectrum Disorder: revealing the gap

BACKGROUND

Alcohol use during pregnancy can result in a continuum of effects including growth deficits, dysmorphology and/or complex patterns of behavioural and cognitive difficulties that influence an individual's functioning throughout their lifespan. We conducted a systematic review to identify research-based interventions for children and youth with a Fetal Alcohol Spectrum Disorder and areas for future study.

METHODS

We identified the substantive literature by searching 40 peer-reviewed and 23 grey literature databases, as well as reference lists. We hand-searched eight relevant journals, and undertook a systematic search of Internet sites and review of reports and documents received from key stakeholders. Two reviewers independently assessed eligibility and quality, and extracted data. Given the small number of studies that met all inclusion criteria, both experimental and quasi-experimental studies were included.

RESULTS

Ten intervention studies were identified, of which three were experimental or quasi-experimental, and four were non-experimental. Despite multiple attempts, three studies (two in foreign languages and one unpublished) could not be acquired. A meta-analysis could not be undertaken because the included studies examined different interventions or outcomes. Interventions targeted in the included studies were as follows: (i) psychostimulant medications (methyphenidate, pemoline and dextroamphetamine); and (ii) Cognitive Control Therapy. The identified studies were limited by very small sample sizes and weak designs.

CONCLUSION

There is limited scientific evidence upon which to draw recommendations regarding efficacious interventions for children and youth with a Fetal Alcohol Spectrum Disorder. Clinicians, researchers, service providers, educators, policy makers, affected children and youth and their families, and others need to urgently collaborate to develop a comprehensive research agenda for this population.