Q. Are there any clinical pointers for alcohol
withdrawal in pregnancy?
A. Pregnant women shouldn’t
be excluded from detoxification programs. See details
Women identified to have
heavy drinking patterns and who are unlikely to reduce their consumption should
be referred to professional alcohol treatment. Consistent screening for alcohol
use, followed by education, assessment, and treatment referral, if indicated,
will help to ensure the best possible outcome for all pregnant women and their
babies.
Pregnancy is a relative
indications for inpatient alcohol detoxification as would be: history of severe
withdrawal symptoms, history of withdrawal seizures or delirium tremens,
multiple previous detoxifications, concomitant psychiatric or medical illness,
recent high levels of alcohol consumption, and lack of a reliable support
network.
Most programs choose to treat the
pregnant, alcohol-dependent woman with short-acting barbiturates or
benzodiazepines. Chlordiazepoxide (Librium) and other benzodiazepines, such as
diazepam (Valium) and barbiturates (Phenobarbital, Seconal), are valuable for
symptomatic treatment during medical withdrawal from alcohol. They are also
potentially teratogenic. Some clinicians, therefore, recommend avoiding their
use if at all possible. The risks versus the possible benefits of their use
need to be assessed.
Disulfiram (Antabuse) is
contraindicated during pregnancy. Its use has been associated with clubfoot,
VACTERL syndrome (a pattern of congenital anomalies), and phocomelia of the
lower extremities The woman who conceives while taking this drug should receive
counseling before deciding to continue the pregnancy
Follow withdrawal
schedule. Programs use different drugs to withdraw patients from alcohol. Drugs
used include chlordiazepoxide, phenobarbital, and diazepam.
- Typical withdrawal schedules using chlordiaze-poxide include 25 to 50 mg 4 times a day for the first 2 days, decreasing gradually to 10 mg 4 times a day for days 8 through 10.
- Typical withdrawal schedules using phenobarbital include 15 to 60 mg by mouth every 4 to 6 hours as needed for the first 2 days, decreasing gradually to 15 mg by the 4th day.
- Typical withdrawal schedules using diazepam include 10 mg 4 times a day; 10 mg every 2 hours as needed for withdrawal symptoms with a maximum of 150 mg/24 hours; decreasing gradually at a rate of 20 to 25 percent over approximately 5 days.
- The loading dose protocol with diazepam is accomplished with doses given according to withdrawal symptomatology. When withdrawal symptoms are stabilized, the long half-life of diazepam alleviates the need for further medication in most cases.
Monitor for signs
and symptoms of alcohol withdrawal syndrome (AWS). The use of withdrawal
assessment scales can be valuable in determining the need for further
medication. Monitor for the following:
- Vital signs (temperature, blood pressure, pulse)
- Delirium (orientation)
- Wernicke's encephalopathy (nystagmus)
- Psychosis (hallucinations, inappropriate thinking)
- Irritability (tremors, increased reflexes)
- Increased autonomic reflexes (goosebumps, sweating)
- Fetal well-being (fetal heart tones, sonograms, or Non-Stress Test) as appropriate for gestational age
The following
excerpt is from the State of Arizona Governor's Action Plan: Entitled:
Guidelines for Identifying Substance-Exposed Newborns. This reminds us
that the detoxification and treatment of the mother is inherently linked with
the infant whether long term affects are expected or not.
These maternal
and infant screening guidelines to me as part of our MCH Epi coordinator work
group interactions. From the Arizona intro:
From
MCH HQE
Let's look at some numbers:
US all races births = 4
million a year so 500,000 as reported from the study above is about 12.5% users
and 2% (80,000) binge drinking.
AI/AN vital stats are about
40,000 births a year so a 12.5% if extrapolated gives a crude number of 5000
users and 800 a year who binge drink. There is no reason to think that we are
lower than the US all races rate. Taking another perinatal morbidity that
of gestational DM prevalence of around 7% we can get the magnitude of the
issue.
Suggested reading
Medical
Withdrawal From Alcohol - Pregnant,
Substance-Using Women, Treatment Improvement Protocol (TIP) Series 2
Endnotes: Pregnant,
Substance-Using Women, Treatment Improvement Protocol (TIP) Series 2
Table
of Contents: Pregnant, Substance-Using
Women, Treatment Improvement Protocol (TIP) Series 2
Sanchez, L. Pregnancy,
addiction and mental health. In: A Guide to the Detoxification of Alcohol
and Other Drug-Dependent Pregnant Women. Cambridge, MA: Coalition on Addiction,
Pregnancy, and Parenting, 1991
See Sample Procedure
(below)
Related topics
Fetal alcohol syndrome:
does alcohol withdrawal play a role?
Alcohol use by a pregnant
woman may interfere with the development of her fetus. Newborns whose mothers
are intoxicated during delivery can experience withdrawal symptoms, such as
tremors and even seizures. It is likely that withdrawal also can occur during
fetal development. Thus, the possibility exists that withdrawal by the pregnant
woman may exacerbate alcohol's adverse effects on her fetus. One potential
mechanism through which alcohol withdrawal might damage the fetus involves the
receptor for the neurotransmitter glutamate (i.e., the N-methyl-D-aspartate
[NMDA] receptor). This receptor plays a crucial role during neuronal
development. Excessive activation of the NMDA receptor, which occurs during
withdrawal, may lead to neuronal cell death. Animal studies suggest that these
effects may contribute to behavioral deficits following prenatal exposure to
alcohol.
Thomas JD,
Riley EP.Fetal alcohol syndrome: does alcohol
withdrawal play a role? Alcohol Health Res World. 1998;22(1):47-53.
Symptoms of neonatal
ethanol withdrawal
Neonatal withdrawal symptoms
in 15 cases of fetal alcohol syndrome with maternal intoxication at time of
delivery, reported in 9 studies, are compared with symptoms reported in 138
cases of neonatal narcotic withdrawal. Seen frequently in ethanol but rarely in
narcotic withdrawal are abdominal distention and opisthotonos. Seen frequently
in narcotic but rarely in ethanol withdrawal are high pitch cry, frequent
yawning, excessive sucking, mottling of the skin, excoriation, nasal
stuffiness, excess sweating, sleeplessness and diarrhea. Seen frequently in
both are increased muscle tonicity and tremors; however, convulsions are rare
in narcotic yet are fairly frequent in neonatal ethanol withdrawal
Robe LB,
et al Symptoms of neonatal ethanol
withdrawal. Curr Alcohol. 1981;8:485-93.
QT prolongation in the newborn
and maternal alcoholism
I discuss a newborn whose
mother is addicted to alcohol. On the third day of life, the newborn was found
to have ventricular tachycardia. After spontaneous termination of the abnormal
rhythm, the duration of the corrected QT interval was 0.48 s. During the next
days, the duration of the interval normalized, and has now remained stable for
5 years. I conclude that the so-called "alcohol withdrawal syndrome of the
newborn" might cause postnatal prolongation of the QT interval
Krasemann T.
QT prolongation in the newborn and
maternal alcoholism. Cardiol Young. 2004 Oct;14(5):565-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15680082&query_hl=6
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15680082&query_hl=6
Other
Alcohol withdrawal syndrome,
Bayard M et al American Family Physician
Substance abuse in pregnancy, UpToDate
Alcohol
withdrawal syndromes, UpToDate
Treatment of alcohol
withdrawal
Introduction to alcohol
withdrawal
Delerium Tremens
Withdrawal Syndromes
Drug Update: Alcohol
Withdrawal - Brief Article
Resources
National Guidelines
Clearinghouse
Cochrane Library
Background
The US Surgeon General and the
Secretary of Health and Human Services recommend abstinence from alcohol for
women planning pregnancy, at conception, and during pregnancy because a safe
level of prenatal alcohol consumption has not been determined. However,
prenatal alcohol use appears to be increasing; approximately 20 percent of
women will drink at least one alcoholic beverage during pregnancy. A study by
the Centers for Disease Control and Prevention found the rate of frequent
drinking (ie, more than seven drinks per week or more than five drinks per
occasion) by pregnant women increased from 0.8 to 3.5 percent between 1991 and
1995 . In addition, the overall rate of fetal alcohol syndrome (FAS) reported
in 1993 was almost seven-fold higher than the 1979 rate (6.7 versus 1.0 per
10,000 births).
These increases may reflect
enhanced awareness and diagnosis of FAS or an absolute increase in the number
of affected infants.and the diagnosis of FAS. The most recent prevalence data
available comes from surveillance data from four states (Alaska, Colorado,
Arizona, New York) for 1995 to 1997: prevalence of FAS was 0.3 to 1.5 cases per
1000 liveborn infants with the highest prevalence among blacks, American
Indians, and Alaskan Natives.
There is no exact dose-response
relationship between the amount of alcohol consumed during the prenatal period
and the extent of damage caused by alcohol in the infant (see below). Infants
whose mothers consume alcohol during pregnancy can have fetal alcohol effects
(FAE), alcohol-related birth defects (ARBD), FAS, or they may be normal. The
term fetal alcohol spectrum disorder has been coined to describe the broad
range of adverse sequelae in alcohol exposed offspring.
Patterns of maternal alcohol
consumption and socioeconomic and ethnic factors also affect outcome. For
example, binge drinking exerts a potentially greater negative effect than
comparable consumption of low amounts of alcohol over a several days (eg, five
drinks in one sitting versus one drink a day for five days). Older maternal
age, high parity, and being African-American or Native American appear to increase
the risk of FAS for unknown reasons.
Identifying
maternal alcohol use — The typical questions asked about the
quantity and frequency of alcohol use are less helpful in the assessment of
prenatal alcohol consumption than in other populations. This discordancy is due
to modification of alcohol consumption once pregnancy is recognized and the
fact that traditional alcohol screening measures were developed in male
alcoholics.
The T-ACE is a screening instrument
designed specifically for the identification of pregnancy risk drinking, which
refers to the consumption of enough alcohol to potentially harm the fetus. This
is seven drinks per week according to the most recent definition. However,
lesser amounts of perinatal alcohol use (more than three drinks per week) have
been associated with adverse outcomes, such as a two-fold increase in
spontaneous abortion. The T-ACE questions are:
How many drinks does it take
for you to feel high (Tolerance)? Do you feel Annoyed by
people complaining about your drinking? Have you ever felt the need
to Cut down on your drinking? Have you ever had a drink
first thing in the morning (Eye-opener)?
One point is given for each
affirmative answer to the Annoy, Cut-down, and Eye-opener questions; two points
are allotted if a woman reports tolerance to more than two drinks. A score of
two or more is a positive score. The overall sensitivity (ie, the probability
that a woman who is a risk drinker scores positive) of T-ACE is 69 percent,
with specificity of 85 percent.
An in-depth discussion of screening
and diagnosis of women with alcohol problems can be found separately.
Treatment
— A positive screen provides an opportunity to proceed with a careful,
non-judgmental assessment of a patient's current and past alcohol consumption.
This focus on drinking behavior can be beneficial. As an example, one trial
randomized 250 pregnant women with a positive alcohol screen and alcohol
consumption in the six months before study enrollment to either comprehensive
alcohol assessment only or to the same comprehensive assessment with a brief
intervention. Both groups of women reduced their antepartum alcohol consumption
by one to two thirds on average. The impact of assessment and brief
intervention was confirmed in a follow-up randomized trial; in addition, this
trial showed that including a partner chosen by the patient during treatment
led to greater reduction in alcohol use, particularly among heavy drinkers.
Women identified to have heavy
drinking patterns and who are unlikely to reduce their consumption should be
referred to professional alcohol treatment. Consistent screening for alcohol
use, followed by education, assessment, and treatment referral, if indicated,
will help to ensure the best possible outcome for all pregnant women and their
babies.
Perinatal outcome
— Alcohol appears to have potentially negative effects throughout pregnancy,
not just the first trimester. As an example, a longitudinal study on 595
children reported that alcohol exposure during the second trimester predicted
deficits in reading, spelling, and arithmetic (measured on the Wide Range
Achievement Test — Revised). The effect of prenatal alcohol exposure persisted
after controlling the analysis for the relationship between IQ and achievement.
Neonatal alcohol withdrawal is characterized by jitteriness, irritability, and
poor feeding in the first 12 hours of life.
Stillbirth and FAS are the most
severe consequences of prenatal alcohol exposure. In one large epidemiologic
study, an increased rate of stillbirth was noted across all categories of
alcohol intake, even after adjustment for confounders (eg, smoking,
prepregnancy weight). The rate of death from fetoplacental dysfunction rose
from 1.37 per 1000 births for women consuming less than one drink per week to
8.83 per 1000 births for women consuming greater than or equal to five drinks
per week.
The prevalence of FAS among
offspring of moderate to heavy drinkers (1 to 2 oz absolute alcohol per day)
and chronic alcoholics is 10 to 50 percent. The diagnosis is based upon four
criteria, all of which must be present:
Prenatal alcohol exposure
(confirmed or unconfirmed) Growth restriction (prenatal
and postnatal) Facial malformation Neurodevelopmental disorder
The typical FAS face has short
palpebral fissures, a thin upper lip, an abnormal philtrum, and a hypoplastic
midface.
Long-term problems include
dental malalignment, malocclusion, myopia, and eustachian tube dysfunction.
Neurodevelopmental delays include deficits in language, motor, learning,
decreased IQ (mean 63), and visual-spatial functioning. Hyperactivity and
attention deficits are common behavioral problems in these children, as are
poor judgment and difficulty in social situations. Low-level prenatal alcohol
exposure also appears to have adverse effects. There is no confirmed
"safe" level of alcohol exposure during pregnancy
*SAMPLE PROCEDURE:
1.
Patients to be admitted solely for
alcohol withdrawal treatment are to be seen first by a physician in the ER or
outpatient clinic.
2.
A consistent approach to the
patient is very important, and good communication among all staff is vital.
3.
The goals of the admission to Inpatient for alcohol withdrawal are to
monitor the patients with consistency, to medicate patients appropriately, and
to assist the patient in developing a long-term plan for sobriety.
4.
The local Alcohol Program and/or the local Social Services Dept. will
evaluate all patients admitted for detoxification during their Inpatient stay.
5.
The decision to admit outpatients for treatment of alcohol withdrawal
will depend on the severity of symptoms, other medical problems, and the
psychosocial home environment. The attached
algorithm should assist in the decision making process.
6.
The Inpatient unit is to be appropriately staffed to adequately monitor
patients per the attached detoxification protocol.
7.
Patients should complete the
alcohol assessment from local program as soon as possible, as evidence of their
commitment to long-term sobriety.
8.
For Inpatients that are not eligible for local Alcohol Program, the
local Social Services Dept. will network with other local Tribal Alcohol and
Social Services Depts. to arrange for final disposition.
9.
Alcohol Withdrawal Assessment. The initial assessment of the patient
with alcoholism or drug dependency should include the spiritual orientation,
family history of alcohol abuse, history of physical or sexual abuse and the
patient’s sexual history or orientation.
10. Treatment Categories. There are four categories that need to be
addressed in respect to the need for admission to the Inpatient unit.
a.
Category 1: Patients with emergent medical problems also in need of
alcohol withdrawal treatment. These
patients obviously need admission for treatment of their emergent problem but
should also have careful attention given to their withdrawal status. The following conditions require monitored
treatment of withdrawal:
·
Severe tremulousness or hallucinosis
·
Significant dehydration
·
Fever above 101 F
·
Documented seizure in a patient with no known seizure disorder
·
Encephalopathy
·
Wernicke’s encepholapathy (ataxia, nystagmus, internuclear
opthalmoplegia)
·
Head trauma with a documented episode of unconsciousness
·
Presence of major complication or associated disease:
Acute hepatic decomposition
Respiratory failure
Respiratory infection
Gastrointestinal bleeding
Pancreatitis
Severe malnutrition
Ketoacidosis
·
Known history of previous episodes of withdrawal that progresses to
full-blown delirium, psychosis, or seizures if left untreated
b.
Category 2: Patients with severe
acute withdrawal from alcohol or other drugs. These patients need admission for
monitoring and treatment of their withdrawal state.
c.
Category 3: Patients in moderate
withdrawal who desire help in withdrawing from drugs or alcohol. These patients should be admitted electively
as space is available. They should be
sober and demonstrate a firm commitment to detoxification and long term
rehabilitation. Outpatient withdrawal
treatment may be offered if the setting is appropriate. Outpatient withdrawal treatment can be
provided if all of the following conditions apply:
·
The patient has a support system (family and friends) that is able to
provide monitoring of medication use and withdrawal signs.
·
The patient’s history of substance abuse, including alcohol, is of
short duration.
·
The patient has not failed in previous attempts at outpatient
withdrawal.
·
The patient is not suicidal.
·
The patient resides near medical facilities for a follow-up as needed.
d.
Category 4: Circumstances that
permit postponement of admission are as follows:
·
Acutely intoxicated patients who have no desire to stop drinking. After
careful assessment, these patients may be offered admission. Assistance should be offered for the family
when feasible. It may be optimal to
postpone the
opportunity
for admission until they are sober and demonstrate a commitment to long-term
sobriety.
·
Acutely intoxicated patients who have been admitted to the local
medical center more than two (2) times in the last 6 months for alcohol
detoxification and have not committed to long term sobriety. These patients should be offered treatment
options including available outpatient substance abuse counseling. Assistance should be offered for the family
when feasible. It may be optimal to
postpone the opportunity for admission until they are sober and demonstrate a
commitment to long-term sobriety. This
will be documented on the medical record.
CCC Editorial Comment
It was good to see a policy in which pregnancy was not
an automatic exclusion criterion. One
problem is that too many alcohol treatment programs look at the patient who is
pregnant as a "dual diagnosis," and immediately exclude them.
Hence, there are very few
available beds for pregnant women for detoxification.
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