Clinical Practice Guidelines Antenatal care - Module I

10.2 Alcohol

Page last updated: 02 April 2013

Alcohol consumption increases the risk of injury in the short-term and chronic disease in the longer term. Drinking in pregnancy can have significant effects on fetal development.

10.2.1 Background

Alcohol consumption among pregnant women in Australia

  • Most Australian women consume alcohol once a month or more, with 18% of women aged 18–23 years having five or more drinks on one occasion, once a week or more (Young & Powers 2005).
  • Rates of drinking during pregnancy are high, with recent Australian surveys reporting rates of 47% in a national survey (Wallace et al 2007) and 59% in a West Australian study (Colvin et al 2007).
  • Drinking levels in the period before pregnancy are also high. In the West Australian survey, 14% of respondents reported drinking five or more standard drinks on a typical occasion during this period (Colvin et al 2007). As many pregnancies are unplanned (47% in the West Australian survey), many fetuses may inadvertently be exposed to alcohol before pregnancy is confirmed.
  • Studies into drinking among Aboriginal women in some areas have found that between 19% and 44% of Aboriginal women drink alcohol in pregnancy (Zubrick et al 2005; Zubrick 2006; Hayes 2001) and between 10% and 19% drink at harmful levels (Zubrick et al 2006; Hayes 2001).

Risks associated with alcohol consumption in pregnancy

  • High-level and/or frequent intake of alcohol in pregnancy increases the risk of miscarriage, stillbirth and premature birth (O’Leary 2004).
  • Alcohol crosses the placenta and nearly equal concentrations in the mother and fetus can be attained. Exposure of the fetus to alcohol may result in a spectrum of adverse effects, referred to collectively as fetal alcohol spectrum disorders (FASD). Of these, fetal alcohol syndrome (FAS) has been described in children exposed to high levels of alcohol in utero as a result of either chronic or intermittent maternal alcohol use (Lemoine et al 1968; Jones et al 1973; Hoyme et al 2005; Astley & Clarren 2000). These children have characteristic facial abnormalities (and often a range of other birth defects), impaired growth and abnormal function or structure of the central nervous system. The diagnosis may not be evident at birth. However, not all children exposed to alcohol during pregnancy are adversely affected, or affected to the same degree. Expression of FAS appears to depend on other factors including (O’Leary 2004): the timing of alcohol intake in relation to the stage of fetal development; the pattern and quantity of alcohol consumption (dose and frequency); and socio-behavioural risk factors (maternal age/duration of drinking, lower socioeconomic status, race, genetic differences, polydrug use).
  • A number of alcohol-related birth defects (ARBD) and alcohol-related neurodevelopmental disorders (ARND) have also been described following exposure to alcohol during pregnancy and can be included, with FAS, under the umbrella term of FASD (Hoyme et al 2005; Astley & Clarren 2000). Although children with ARND do not have birth defects, they have significant developmental, behavioural and cognitive problems similar to children with FAS.
  • People with FASD experience lifelong problems, including learning difficulties and disrupted education, increased rates of mental illness, drug and alcohol problems and trouble with the law (Streissguth et al 2004).
  • The effects of alcohol exposure on fetal development occur throughout pregnancy (including before the pregnancy is confirmed), with the developing fetus being most vulnerable to structural damage during the first three to six weeks of gestation (O’Leary 2004). Effects also vary depending on the dose of alcohol and the pattern of consumption. The most serious of the adverse pregnancy outcomes occur when pregnant women consume high levels of alcohol frequently.

10.2.2 Discussing alcohol consumption in pregnancy

While there is convincing evidence linking chronic or intermittent high level alcohol intake with harms, including adverse pregnancy outcomes and FASD, there remains uncertainty about the potential for harm to the fetus if a woman drinks low levels of alcohol during pregnancy. It is important that all women of child-bearing age are aware, before they consider pregnancy, of both this uncertainty and the potential risks of harm, so they can make informed decisions about drinking in pregnancy. Health professionals should highlight that:
  • the risk is higher with high alcohol intake, including episodic intoxication;
  • the risk appears to be low with low alcohol intake; and
  • it is impossible to determine how other maternal and fetal factors will alter risk in the individual.
The high rates of drinking in Australian women, including pregnant women, and the high rates of unplanned pregnancy suggest that, regardless of policy, many fetuses will be inadvertently exposed to alcohol. Assessment of women who have consumed alcohol before knowing that they were pregnant should include appraisal of how much alcohol was consumed and at what stage in the pregnancy. Efforts should be made not to induce unnecessary anxiety for isolated episodes of drinking. Women who drank alcohol before they knew they were pregnant or during pregnancy should be reassured that the risk to the fetus is likely to be low if they had drunk at low risk levels. Women who remain concerned should seek specialist medical advice. Health professionals who are uncertain how to advise pregnant women seeking information concerning the potential for alcohol-related harm should seek expert advice from specialist medical services.
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Consensus-based recommendation

xi. Advise women who are pregnant or planning a pregnancy that not drinking is the safest option as maternal alcohol consumption may adversely affect the developing fetus.

Section 7.5.2 includes an example question that may assist in asking women about their alcohol consumption.

10.2.3 Practice summary — advising women about alcohol

When — At the first antenatal visit
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
  • Discuss alcohol consumption during pregnancy — Explain that not drinking is the safest option and the risk of harm to the fetus is highest when there is high, frequent maternal alcohol intake. However the level of risk to the individual fetus is influenced by maternal and fetal characteristics and is hard to predict.
  • Assist women who consumed alcohol before knowing they were pregnant — Advise these women that risk of harm to the fetus is likely to be low if a woman has consumed only small amounts of alcohol before she knew she was pregnant or during pregnancy.
  • Take a holistic approach — If there are concerns about the effects of a woman’s alcohol consumption on the pregnancy, specialist medical advice should be sought. Women who find it difficult to decrease their alcohol intake will require support and treatment and should be offered referral to Drug and Alcohol services.

10.2.4 Resources

Assessment tools

T-ACE and TWEAK are validated and reliable tools that have been developed for use with pregnant women. However, they may not be useful with lower levels of drinking that may still be risky in pregnancy.
AUDIT is a validated tool, but is not designed specifically for use during pregnancy.

AUDIT

Thomas F. Babor John C. Higgins-Biddle John B. Saunders Maristela G. Monteiro Babor TF, Higgins-Biddle JC, Saunder JB et al (2001)The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care Second Edition. Geneva:
World Health Organization. For more information please visit World Health Organisation website.

TWEAK

T Tolerance: How many drinks can you hold?
W Have close friends or relatives Worried or complained about your drinking in the past year?
E Eye Opener: Do you sometimes take a drink in the morning when you get up?
A Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
K (C) Do you sometimes feel the need to Cut down on your drinking?

Scores are calculated as follows: A positive response to question T on Tolerance (ie consumption of more than five drinks) or question W on Worry yields 2 points each; an affirmative reply to question E, A, or K scores 1 point each. A total score of 2 or more points on the TWEAK indicates a positive outcome for pregnancy risk drinking.

T-ACE

T Tolerance: How many drinks does it take to make you feel high?
A Have people Annoyed you by criticising your drinking?
C Have you ever felt you ought to Cut down on your drinking?
E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Scores are calculated as follows: a reply of More than two drinks to question T is considered a positive response and scores 2 points, and an affirmative answer to question A, C, or E scores 1 point, respectively. A total score of 2 or more points on the T-ACE indicates a positive outcome for pregnancy risk drinking.
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Treatment guidelines

DoHA (2007) Alcohol Treatment Guidelines for Indigenous Australians. Canberra: Commonwealth of Australia.For more information please visit Department of Health and Ageing website.
DoHA (2009) Guidelines for the Treatment of Alcohol Problems. Canberra: Commonwealth of Australia. For more information please visit Department of Health and Ageing website.
DoHA (2009) Quick Reference Guide for the Treatment of Alcohol Problems. Canberra: Commonwealth of Australia. For more information please visit Department of Health and Ageing website.
Ministerial Council on Drug Strategy (2006) National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn. Sydney: NSW Health. For more information please visit NSW Health Department website.
NHMRC (2009) Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Canberra: National Health and Medical Research Council. For more information please visit National Health and Medical Research Council website.

10.2.5 References

Astley SJ & Clarren SK (2000) Diagnosing the full spectrum of fetal alcohol-exposed individuals: introducing the 4-digit diagnostic code. Alcohol 35(4): 400–10.

Colvin L, Payne J, Parsons D et al (2007) Alcohol consumption during pregnancy in nonindigenous West Australian women. Alcohol Clin Exp Res 31(2): 276–84.

Hayes L (2001) An Evaluation of a District Rural Health Service Data Collection on Social Health Risk Factors during Pregnancy. Unpublished Masters Thesis, Australian National University, Canberra.

Hoyme HE, May PA, Kalberg WO et al (2005) A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 Institute of Medicine criteria. Pediatrics 115: 39–47.

Jones KL, Smith DW, Ulleland CN et al (1973) Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1: 1267–71.

Lemoine P, Harousseau H, Borteyru JP et al (1968) Les enfants des parents alcoholiques: anomolies observees a propos de 127 cas. [The children of alcoholic parents: anomalies observed in 127 cases.] Quest Medical 25: 476–82.

O’Leary CM (2004) Fetal alcohol syndrome: diagnosis, epidemiology, and developmental outcomes. J Paediatr Child Health 40: 2–7.

Streissguth AP, Bookstein FL, Barr HM et al (2004) Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev & Behavioral Pediatrics 25: 228–38.

Wallace C, Burns L, Gilmour S et al (2007) Substance use, psychological distress and violence among pregnant and breastfeeding Australian women. Aust NZ J Public Health 31: 51–56.

Young A & Powers J (2005) Australian Women and Alcohol Consumption 1996–2003. Australian Longitudinal Study on Women’s Health (ALSWH) report to the Australian Government Department of Health and Ageing. Commonwealth of Australia.

Zubrick SR, Silburn SR, Lawrence D et al (2005) The Western Australian Aboriginal Child Health Survey: The Social and Emotional Wellbeing of Aboriginal Children and Young People. Curtin University of Technology and Telethon Institute for Child Health Research, Perth.

Zubrick SR, Silburn SR, De Maio J et al (2006) The Western Australian Aboriginal Child Health Survey: Improving the Educational Experiences of Aboriginal Children and Young People. Curtin University of Technology and Telethon Institute for Child Health Research, Perth.

1 The information in this section, including the consensus-based recommendation, is based on Guideline 4 in NHMRC (2009) Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Canberra: National Health and Medical Research Council. Literature on prevalence of alcohol consumption and associated risks during pregnancy published subsequent to the NHMRC guidelines has not been reviewed. For more information please visit National Health and Medical Research Council website.