9/5/05njm

4/24/06njm

**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:

  ![](media/image1.jpeg){width="5.4375in"
height="0.7916666666666666in"}                   

[[http://www.governor.state.az.us/cps/documents/SenGuidelines.pdf]{.underline}](http://www.governor.state.az.us/cps/documents/SenGuidelines.pdf)

 

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

<http://ncadi.samhsa.gov/govpubs/bkd107/2d3.aspx>

Endnotes: Pregnant, Substance-Using Women, Treatment Improvement
Protocol (TIP) Series 2

<http://ncadi.samhsa.gov/govpubs/bkd107/2g.aspx#TIP2.FN12>

Table of Contents: Pregnant, Substance-Using Women, Treatment
Improvement Protocol (TIP) Series 2

<http://ncadi.samhsa.gov/govpubs/bkd107/default.aspx>

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](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Thomas+JD"%5BAuthor%5D),
[Riley
EP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Riley+EP"%5BAuthor%5D).Fetal
alcohol syndrome: does alcohol withdrawal play a role? Alcohol Health
Res World. 1998;22(1):47-53.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15706733&query_hl=3>

**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](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Robe+LB"%5BAuthor%5D),
et al Symptoms of neonatal ethanol withdrawal. Curr Alcohol.
1981;8:485-93.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7343193&query_hl=8]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7343193&query_hl=8)

**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](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Krasemann+T"%5BAuthor%5D).
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>

**Other**

Alcohol withdrawal syndrome, Bayard M et al American Family Physician

<http://www.aafp.org/afp/20040315/1443.html>

[Substance abuse in
pregnancy](http://www.uptodateonline.com/application/topic/topicText.asp?file=maternal/5807#top),
UpToDate

<http://www.uptodateonline.com/application/topic.asp?file=maternal/5807>

Alcohol withdrawal syndromes, UpToDate

[[http://www.uptodateonline.com/application/topic.asp?file=cc_medi/24574&type=A&selectedTitle=1\~10]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=cc_medi/24574&type=A&selectedTitle=1~10)

Treatment of alcohol withdrawal

<http://www.niaaa.nih.gov/publications/arh22-1/38-43.pdf>

Introduction to alcohol withdrawal

<http://www.niaaa.nih.gov/publications/arh22-1/04-04.pdf>

Delerium Tremens

<http://www.emedicine.com/EMERG/topic123.htm>

Withdrawal Syndromes

<http://www.emedicine.com/EMERG/topic643.htm>

Drug Update: Alcohol Withdrawal - Brief Article

<http://www.findarticles.com/p/articles/mi_m0BJI/is_23_30/ai_68642766>

**Resources**

National Guidelines Clearinghouse

<http://www.guidelines.gov/>

Cochrane Library

<http://www.update-software.com/cochrane/abstract.htm>

**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:

  ![](media/image2.png){width="6.25e-2in"
height="7.291666666666667e-2in"} How many drinks does it take for you to
feel high (Tolerance)?\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Do you feel Annoyed by people
complaining about your drinking?\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Have you ever felt the need to Cut down
on your drinking?\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} 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:

  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Prenatal alcohol exposure (confirmed or
unconfirmed)\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Growth restriction (prenatal and
postnatal)\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Facial malformation\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} 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:

        ```{=html}
        <!-- -->
        ```
        -   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]{.underline}**

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.