Managing alcohol use in pregnancy​

Brief interventions during pregnancy

Brief interventions are short motivational counselling sessions that are recommended for pregnant women who report low to moderate levels of alcohol use. Brief interventions have been shown to help women achieve abstinence or reduce alcohol consumption during pregnancy (Chang et al., 2000, 2005).

Brief interventions are also associated with improved newborn outcomes, such as increased birth weight and length, as well as reduced fetal mortality (O'Connor & Whaley, 2007).

Brief interventions with pregnant women should include the following elements:

• assessment and feedback to increase awareness
• advice to reduce or eliminate alcohol use
• assistance with goal setting – exploring the woman's interest in changing her drinking behaviour and discussing situations where she is likely to drink, with suggested alternatives to drinking, such as attending an AA or support group meeting (Carson et al., 2010; Chang et al., 2005; O'Connor et al., 2007; Rosett et al., 1983).

Characteristics of alcohol treatment for pregnant women

Pregnant women with an alcohol use disorder require more intense and specialized interventions to achieve abstinence (Carson et al., 2010).

Treatment for alcohol problems in pregnant women should involve:

• woman-centred care (e.g., involving women in planning treatment and developing goals)
• a harm-reduction philosophy (to reduce harms associated with alcohol use)
• a respectful and non-judgmental approach
• comprehensive care, including prenatal care and substance use counselling
• integrated care to reduce fragmentation and improve co-ordination of services (Health Canada, 2001a; Milligan et al., 2011).

Monitoring pregnant women with a history of alcohol use during pregnancy

In addition to routine antenatal care, the following investigations should be considered:

• Assess for fetal malformations with a detailed level-two ultrasound.
• Monitor for fetal growth (using ultrasound scans) and fetal well-being (biophysical profile), as needed.

Relapse prevention strategies during pregnancy

Pharmacotherapy options for relapse prevention are contraindicated during pregnancy.

Referral to a treatment program for more specialized counselling can help pregnant women with an alcohol use disorder to achieve and maintain abstinence.

Managing alcohol withdrawal during pregnancy

Alcohol withdrawal occurs within six to 12 hours after sudden cessation of drinking. Withdrawal symptoms and signs may include tachycardia, hypertension, nausea, vomiting, tremor, agitation, hallucinations and grand mal seizures.

Alcohol withdrawal may be associated with adverse maternal and neonatal outcomes such as premature labour; therefore, medical withdrawal of alcohol-dependent pregnant women needs to be conducted in an inpatient setting.

The U.S. Center for Substance Abuse Treatment (1993) recommends the following withdrawal protocol for pregnant women:

Use the CIWA scale and benzodiazepine loading with diazepam for symptomatic treatment.

• Admit the woman to hospital for medical detoxification.
• Obtain blood alcohol concentration and urine toxicology.
• Offer thiamine 100 mg intramuscular once daily for three days, folic acid 5 mg once daily, and prenatal vitamin daily.
• Monitor hydration and electrolytes.
• Offer non-pharmacological interventions to correct nutritional deficiencies, maintain physical comfort and encourage adequate rest.
• Monitor for fetal well-being, depending on gestational age.
• Consider referral to a treatment program for continued care as part of discharge planning.

Risks of drinking alcohol while breastfeeding

After the mother ingests alcohol, it passes into her breast milk within 30 to 60 minutes at levels similar to those found in her bloodstream. Among women who drink heavily, alcohol levels are higher in their breast milk than in their blood (World Health Organization [WHO], 2014).

The infant brain may be affected by small quantities of alcohol due to slower metabolism and excretion of alcohol in infants compared to adults.

Maternal alcohol consumption in various amounts has been associated with decreased milk flow and adverse neonatal consequences, such as impaired motor development, altered sleep-wake patterns and decreased milk intake (Koren, 2002; Little et al., 1989; Mennella, 2001; Mennella & Gerrish, 1998; WHO, 2014). The long-term effects of alcohol use during breastfeeding are not known.

There is no known safe level of alcohol in breast milk.

Using low levels of alcohol during lactation does not mean the woman should stop breastfeeding, because this level of drinking is unlikely to cause significant problems. However, women could delay breastfeeding for about two hours after each standard drink to allow the alcohol to clear from their breast milk (Koren, 2002; WHO, 2014).

Mothers can consider breastfeeding unless the risks of alcohol exposure outweigh the benefits of breastfeeding. Since breastfeeding provides many benefits to the infant, it should be encouraged, and women should be counselled to abstain from alcohol while breastfeeding.

Daily heavy alcohol use may have negative consequences for the infant and may shorten the duration of breastfeeding. Because alcohol use disorders in breastfeeding women pose a high risk to the infant, it is preferable for these women to use breast milk alternatives (WHO, 2014).

Postpartum relapse prevention

Numerous triggers for relapse in women with alcohol problems can appear during the postpartum period, including:

• pain, fatigue, sleep deprivation and other discomforts
• stress of role adaptation and caring for a newborn (along with other children, for some women)
• ambivalence about parenting
• shifts in relationships with partner and family members
• interactions with child welfare agencies, courts and criminal justice agencies
• temporary or permanent loss of custody, whether voluntary or involuntary; reunification after temporary loss of infant custody
• guilt and grief related to infant illness or death.

The U.S. Center for Substance Abuse Treatment (2009) suggests ways in which clinicians can help women to prevent relapse:

• Recognize that a woman might quit drinking during pregnancy for her unborn child rather than for herself.
• Explore with the mother the risks, for both her and her baby, of continued postpartum alcohol use, as well as the benefits of abstinence.
• Help pregnant women to plan ahead for anticipated triggers in the postpartum period.
• Connect women antenatally to resources for relapse prevention counselling and discuss pharmacological options (e.g., naltrexone, acamprosate) that can be initiated postpartum to maintain abstinence.