Alcohol and pregnancy

Alcohol use in pregnancy includes use of alcohol during gestation, including the time before the woman is aware of the pregnancy.  No amount of alcohol is considered safe to drink while pregnant and there is no safe time point or trimester in pregnancy to drink alcohol.  Fetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person whose mother drank alcohol during pregnancy.  The most severe form of the condition is known as fetal alcohol syndrome (FAS).  Problems may include an abnormal appearance, short height, low body weight, small head size, poor coordination, low intelligence, behavioral problems, hearing loss, and vision problems.  Those affected are more likely to have trouble in school, legal problems, participate in high-risk behaviors, and have trouble with alcohol and recreational drug use.  Alcohol use during pregnancy also can cause spontaneous abortion, stillbirth, low birthweight, and prematurity.   Not all infants exposed to alcohol in utero will have defects related to the alcohol consumption.  The use of alcohol during pregnancy is associated with domestic violence and potential harm to the infant. 

Fetal alcohol syndrome usually occurs when a pregnant woman has more than four drinks per day during the first trimester, with milder symptoms having been found with two drinks per day.  Evidence of harm from less than two drinks per day or ten drinks per week is not clear.  Most health organisations recommend complete abstinence from alcohol during the first three months of pregnancy, when the fetus is most susceptible to the mutative effects of alcohol, and recommend overall moderation throughout the entire pregnancy. 

Embryology 
Different body systems in the infant grow, mature and develop at specific times during gestation.  The consumption of alcohol during one or more of these developmental stages may only result in one or few conditions. 

During the first weeks of pregnancy babies grow at a rapid pace, even before the mothers know they are pregnant.  From conception and to the third week, the most susceptible systems and organs are the brain, spinal cord, and heart.  These crucial organs start forming in early stages of pregnancy, which are very sensitive and critical periods in human development.  Though these body systems complete their development later in the pregnancy, the effects of alcohol consumption early in the pregnancy can result in defects to these systems and organs.  During the fourth week of gestation, the limbs are being formed and it is at this point that alcohol can effect the development of arms, legs, fingers and toes.  The eyes and ears also form during the fourth week and are more susceptible to the effects of alcohol.  By the sixth week of gestation, the teeth and palate are forming and alcohol consumption at this time will affect these structures.  Alcohol use in this window is responsible for many of the facial characteristics of fetal alcohol syndrome.  By the 20th week of gestation the formation of organs and organ systems is well-developed.  The infant is still susceptible to the damaging effects of alcohol.  Therefore, it would be safer for women to stop drinking prior to trying to conceive. 

The baby's brain, body, and organs are developing throughout pregnancy and can be affected by exposure to alcohol at any time.   Because every pregnancy is different, drinking alcohol may hurt one baby more than another.  A child that has been affected by alcohol before birth may appear 'normal' at birth.  Intellectual disabilities may not appear until the child begins school. 

Alcohol during pregnancy 
The developing fetus is exposed to the alcohol through the placenta and umbilical cord.  Alcohol metabolizes slowly in the fetus and remains for a long time when compared to an adult because of re-uptake of alcohol-containing amniotic fluid.  Alcohol exposure has serious implications on the developing fetus as well as the mother.  When a woman is planning for pregnancy, she should keep in mind that there is no safe limit for alcohol consumption.  It can lead to premature birth and problems may manifest later as the child continues to grow.  One of the main problematic outcomes in the developing baby is Fetal Alcohol Syndrome, which is characterized by: cleft palate and/or cleft lip, disproportionate physical development of the body, and various disabilities like attention deficiency, low memory and coordination ability, as well as improper functioning of various body organs like the kidneys, heart and bones.  Miscarriage, low birth weight and stillbirth are other common outcomes. 

These effects can be magnified especially during the first and third trimester of pregnancy when the baby is growing rapidly.  Alcohol consumption in the first trimester of pregnancy, which is a crucial developmental stage of fetal growth, can have serious consequences.  The developing fetus can be exposed to alcohol in the earliest weeks of pregnancy.  During the third week, alcohol can affect the heart and central nervous system of the fetus.  If the mother continues to drink, the eyes, legs and arms of the fetus can be adversely affected.  Continuous exposure further through the sixth week can have negative impact on ear and teeth development.  palate and external genitalia can be affected if the mother persists drinking.  During the twelfth week, frequent alcohol exposure can negatively impact the brain development which affects cognitive, learning and behavioral skills before birth.   Consumption of excessive alcohol can lead to Fetal Alcohol Syndrome which can produce irreversible lifetime changes in physical, mental and neurobehavioral development of the fetus.  Alcohol during pregnancy not only affects the developing fetus, but it also has adverse health outcomes on the mother as well.  It can harm the fertility of women who are planning for pregnancy.  Adverse effects of alcohol can lead to malnutrition, seizures, vomiting and dehydration.  The mother can suffer from anxiety and depression which can result in child abuse/neglect.  It has also been observed that when the pregnant mother withdraws from alcohol, its effects are visible on the infant as well.  The baby remains in an irritated mood, cries frequently, doesn't sleep properly, weakening of sucking ability and increased hunger. 

Alcohol consumption during pregnancy may increase the risk that the child will develop acute myeloid leukemia at a young age. 

It is worth to note that alcohol was used as a common tocolytic agent.  Tocolytic agents are drugs that are used to prevent preterm labor (baby born at less than 37 weeks gestation) by suppressing uterine contraction.  However, alcohol is no longer used in current practice due to safety concerns for the mother and her baby.  Cochrane Systematic Review has also shown that ethanol is no better than placebo (sugar water) to suppress preterm birth and neonatal mortality.  Not only that ethanol is worse than other beta-mimetic drugs (type of tocolytic agents) at postponing birth, it also leads to a higher rate of low birthweight babies, babies with breathing problems at birth and neonatal death. 

Signs and symptoms 
When an infant is born and appears to be healthy, the baby may still have non-visible disorders and organ defects due to exposure to alcohol during the pregnancy.  Social problems in the child have been found to be associated with alcohol use during gestation.  Alcohol is a cause of microcephaly.  Alcohol use during pregnancy does not effect the ability to breastfeed the infant.  In addition, an infant may breastfeed even if the mother continues to consume alcohol after the birth.  An infant born to a mother that has an alcohol dependency may go through alcohol withdrawal after the birth. 

One of the major effects of alcohol consumption during pregnancy is Fetal Alcohol Spectrum Disorders (FASDs), of which Fetal Alcohol Syndrome (FAS) is the most severe form.  It is shown that small amounts of alcohol consumed during pregnancy does not show any health related issues in the face, but behavioral issues can be seen.  There is a wide range of symptoms seen in persons suffering from FASDs which include:

Abnormal facial features, such as a smooth ridge between the nose and upper lip (this ridge is called the philtrum)
Small head size
Shorter-than-average height
Low birth weight
Poor coordination
Hyperactive behavior
Difficulty with attention
Poor memory
Difficulty in school (especially with math)
Learning disabilities
Speech and language delays
Intellectual disability or low IQ
Poor reasoning and judgment skills
Sleep and sucking problems as a baby
Vision or hearing problems
Problems with the heart, kidneys, or bones. 

There are four types of FASDs depending on the symptoms: (1) Fetal Alcohol Syndrome, (2) Alcohol-Related Neurodevelopmental Disorder, (3) Alcohol-Related Birth Defects, (4) Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure. 

There are three approaches to treatment of FAS:

(1) At Home- A stable and loving home along with a regular routine, simple rules to follow and where rewards are given for positive behavior is a good environment for children with FAS. 

(2) Medications- Medications are used to specifically treat symptoms of FASDs and not FAS entirely.  Some of the medications used are antidepressants, stimulants, neuroleptics and anti-anxiety drugs. 

(3) Counseling- Children with FAS benefit from behavioral and functional training, social skill training and tutoring.  Support groups and talk therapy not only help the children suffering from FAS, but also help the parents and siblings of these children. 

Treatment
A woman may elect to discontinue alcohol once she knows that she is pregnant.  A woman can have serious symptoms that accompany alcohol withdrawal during pregnancy.  These symptoms can be treated during pregnancy with benzodiazepine tranquilizers. 

Epidemiology
One out of 67 women who drink alcohol during pregnancy will have a child with a birth defect.  The five countries with the highest prevalence of alcohol use during pregnancy were Ireland (about 60%), Belarus (47%), Denmark (46%), the UK (41%) and the Russian Federation (37%).  The lowest prevalence is in those nations whose religious beliefs govern their alcohol consumption.  Birth defects caused by alcohol consumption may be up to 1% in many places.  This may mean that FASD may be higher than anencephaly, Down syndrome, spina bifida and trisomy 18.  Globally, one in 10 women drink alcohol during pregnancy.  Out of this population, 20% binge drink and have four or more alcoholic drinks per single occasion. " Binge drinking is the direct cause of FAS or FASD.  These findings are alarming because half of the pregnancies in developed countries and over 80% in developing countries are unplanned.  That means that many women don’t realize they are pregnant during the early stages and that they continue drinking when pregnant." 

Public health recommendations 
Starting in 1981, the surgeon general of the United States started releasing a warning asking pregnant women to abstain from alcohol for the remainder of gestation.  The American Academy of Pediatrics issued set of recommendations in 2015: "During pregnancy no amount of alcohol intake should be considered safe; there is no safe trimester to drink alcohol; all forms of alcohol, such as beer, wine, and liquor, pose similar risk; and binge drinking poses dose-related risk to the developing fetus."  The World Health Organization recommends that alcohol should be avoided entirely during pregnancy, given the relatively unknown effects of even small amounts of alcohol during pregnancy.  The United Kingdom's National Institute for Health and Clinical Excellence has advised that women abstain from alcohol entirely during the first three months of gestation, and that if women do choose to drink they should drink no more than one or two drinks once or twice a week. 

Controversy 
There has been some controversy surrounding the zero-tolerance approach taken by many countries toward alcohol consumption during pregnancy.  A 2000 article wrote that the concern about the risk of FAS may be inflated beyond the level warranted by existing evidence of its prevalence and impact and argued that equating a low level of drinking with unavoidable harm to the fetus may have negative social, legal and health impacts.  In 2016, an infographic created by the CDC caused controversy by recommending that women of child-bearing age abstain from alcohol if they were not on birth control.  This is because the window for developing fetal alcohol syndrome is very early, before women may know they're pregnant.  However, the recommendation was seen by some as onerous or overly broad, with some sources claiming it "shamed women". 

See also 

Fetal alcohol spectrum disorder
Smoking and pregnancy
Long-term effects of alcohol consumption

References

External links

Harvard health

 
Category:Obstetrics
Category:Women's health
Category:Alcohol abuse
Category:Teratogens
Category:Congenital disorders