Introduction
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Care providers should understand the importance of a non-judgemental approach, show empathy towards the woman, and should be aware of the importance of engaging her into care.1
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Women who use alcohol in pregnancy tend to be poor attenders, and benefit from additional contacts by their Drug and Alcohol Counselor between antenatal visits. The term alcohol refers to ethanol.
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Screening
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Women with a history suggesting alcohol dependency, alcohol withdrawal symptoms in pregnancy, or signs of alcohol intoxication should have their alcohol use assessed with the T-ACE2,3 or other validated Screening Tool (refer to: Appendix 1: T-ACE Questionnaire). The T-ACE score must be recorded in the Antenatal Record, inpatient Progress Notes, or on the Modified Early Warning Score chart as appropriate.
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Assessment
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Referral to the Women's Alcohol and Drug Service should be arranged for women who wish to withdraw from alcohol, those with polysubstance use, and for those who continue to use alcohol and who live in unstable circumstances.
Women's Social Support Services social worker or WADS counsellor/advocate will conduct a psychosocial assessment.
If screening indicates that the woman is likely to continue to use alcohol, she should be referred to Women's Social Support Service.
If pregnant, she should also be referred to the Team Social Worker if homelessness, domestic violence, or mental health issues are suspected.
The quantity, frequency and pattern of alcohol use should be assessed.
The motivation to address alcohol use should be assessed.
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Medical assessment by the Obstetric Medical Fellow (Mon - Fri in hours) or referral to the on-call Physician should be undertaken to assess any health deficits associated with alcohol use.
Initial medical investigations may include liver function tests, full blood examination, coagulation screen, ferritin, vitamin B12, vitamin D and folate levels.
If medical sequelae to nutritional deficiency are present, inpatient referral to the Dietitian should be arranged.
Pregnancy assessment should be made to determine whether or not alcohol use has affected the development of the fetus and should include: a physical assessment to determine whether the fetus is of the expected size, second trimester morphology scanning, and in the third trimester, cardiotocography and amniotic fluid index (AFI) measurement at each visit.
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Caution4 should be exercised if the following are present:
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 | - diabetes
- liver disease
- mental health disorder on medication
- if taking steroids
- recent Emergency department admission
- discrepancy between history of last substance use and the clinical presentation.
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| - history of violent behaviour
- current aggressive behaviour
- past or present suicidal ideation.
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Counseling and support
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The pregnant woman should be counseled4 about the hazard of continuing to use alcohol and given the ‘Alcohol use in pregnancy’ brochure produced by the Women's Alcohol and Drug Service. Support by a Counselor from the Women's Alcohol and Drug Service is recommended.
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Brief interventions in the Outpatient setting (acromyn: FRAMES5)
These interventions should be used selectively to promote referral of the woman to the social worker or to the Women's Alcohol and Drug Service if this has not already been done, and to express empathy.
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| about the risks of continued alcohol intake to the woman's health and the health of the fetus.
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| | for personal choice to reduce the current alcohol intake.
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| | about the importance of changing current drinking patterns should be offered.
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| | choosing to set personal limits/recognizing antecedents of drinking/avoidance of drinking in high-risk situations/pacing ones drinking/coping strategies for everyday problems that lead to drinking.
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| | is an important motivator which facilitates changed behaviour.
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| | is enhanced by encouragement and instilling optimism.
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Management of alcohol withdrawal
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Alcohol withdrawal symptoms may occur as part of a planned alcohol detoxification programme, or may occur unexpectedly in a woman who has not disclosed alcohol use.
Consultation with the Psychiatry Registrar or Duty Psychiatrist should be arranged if the woman has symptoms of mental illness6, or if other anxiolytic, anti-depressant or antipsychotic medicines are currently being used.
Consultation with the Obstetric Medical Fellow or Duty Physician6 or referral to external agencies as detailed in the Management Algorithm, should be considered on a case-by-case basis if there are other health issues associated with alcohol use.
Symptoms of perspiration, tremor, anxiety, agitation, or nausea and vomiting should be assessed using the Alcohol Withdrawal Scale7 (refer to: Appendix 2: Alcohol Withdrawal Scale). Alcohol Withdrawal Scores calculated from the Scale should be recorded in the Progress Notes.
Alcohol withdrawal should be managed with diazepam titration8 by the WADS Duty Consultant based on the Alcohol Withdrawal Score, using diazepam 10-20 mg every two hours until the withdrawal scale score is <10 and anxiety/agitation is relieved.
If the woman is currently using benzodiazepines as well as alcohol, tolerance to benzodiazepines may have developed. Under these circumstances a high dose of diazepam may be required. If a dose of diazepam over 120 mg per day is necessary, consultation with the Drug and Alcohol Clinical Advisory Service (DACAS)9 Consultant is recommended.
Other social or substance abuse issues identified in the Psychosocial Assessment should be appropriately addressed.
Thiamine10 100mg should be given intravenously or intramuscularly, then daily by mouth.
Fluid and electrolyte levels should be assessed and optimised from the commencement of treatment until measurable and satisfactory improvement of alcohol withdrawal symptoms occurs.
If the woman is not pregnant or has delivered and will not be breast-feeding, acamprosate treatment and relapse prevention counselling should be arranged after she is discharged from hospital.
Refer to: Appendix 3: Alcohol Withdrawal Management Algorithm.
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Breastfeeding advice6
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Advice for breastfeeding mothers includes the following:
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- not drinking alcohol is the safest option
- women should avoid alcohol in the first month after birth/delivery until breastfeeding is well established
- thereafter:
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| - alcohol intake should be limited to no more than two standard drinks a day
- women should avoid drinking immediately before breastfeeding
- women who wish to drink alcohol could consider expressing milk in advance.
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Appendices
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Appendix 1: T-ACE Questionaire
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A total score of 2 or greater in these four questions indicates potential risk for pregnancy and identification of prenatal risk.
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How many drinks does it take to make you feel high?
| - 0 = less than or equal to two drinks
- 1 = more than two drinks
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| | Have people annoyed you by criticising your drinking?
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| | Have you felt you ought to cut down on your drinking?
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| | Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
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Appendix 2: Alcohol Withdrawal Scale
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Appendix 3: Alcohol Withdrawal Management: Algorithm
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References and evidence
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Evidence
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There are no prospective trials of key areas of interest as these would be both unethical and inappropriate. Most evidence is observational. Where possible, this guideline is based on meta-analyses and systematic reviews, which synthesize the results from a number of single studies.
A detailed account of this evidence is given in:
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- Australian Guidelines to Reduce Health Risks from Drinking Alcohol 2009:
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| - Alcohol & Mental Health Problems p96
- Interaction with Medications p98
- Lactation, Pregnancy Outcome & Binge drinking p104.
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- T-ACE, in Chang et al, 1998
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- Diazepam substitution therapy in Saitz et al, 1994.
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References
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1. New South Wales Health. National Clinical Guidelines for the management of drug use during pregnancy birth and the early development years of the newborn. 2006, p26-28.
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http://www.health.nsw.gov.au/pubs/2006/ncg_druguse.html
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2. Sokol, R.J. et al. American Journal of Obstetrics and Gynecology 1989; 160: 863-71.
3. Chang et al. Alcohol use and pregnancy: improving identification. Harvard Medical School. Obstet Gynecol. 1998 Jun;91(6):892-8.
4. Admission Eligibility Criteria, Intoxicated or Alcohol/Drug Dependent Person. De Paul House, St Vincent's Hospital Melbourne 2009.
5. Miller, W.R., Rollnick, S. Motivational Interviewing: preparing people for change. 2nd Edn., New York: Guilford, 2002.
6. Australian Guidelines to Reduce Health Risks from Drinking Alcohol
NHMRC Reference No: DS10, 2009. http://www.nhmrc.gov.au/publications/synopses/ds10syn.htm
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7. Alcohol Withdrawal Scale & Alcohol Withdrawal Chart. Melbourne Health, 2009.
8. Saitz R et al, Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994 Aug 17;272(7):519-23.
9. DACAS: Victorian Drug and Alcohol Clinical Advisory Service 1800 812 804
10. Hack, JB, Hoffman, RS. Thiamine before glucose to prevent Wernicke encephalopathy: examining the conventional wisdom. JAMA 1998; 279:583.
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Published: 17 December 2009
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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