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Alcohol in the form of beverages is a licit drug for consumption. It is found throughout the world, and has been
consumed for centuries by both men and women on different occasions. Even so, alcohol is known to cause
dependency among people that have a tendency to become alcoholic, and/or the ones who are exposed to bouts
of depression and stress, frequent use, as well as personal motivations leading to alcohol consumption.
The consumption of alcohol during pregnancy is the most common cause of births of mentally delayed
children among mothers who are drinkers, and the principal cause of fetus malformation in the Western
Hemisphere. The excessive consumption of alcohol by women during pregnancy constitutes one of the most
frequent problems found during pregnancy, and can lead to Fetal Alcohol Syndrome (FAS) endangering the
neural-psychiatric well-being of the progeny of alcoholic women.
Even though the effects of alcoholic consumption during pregnancy have been known for centuries, it has only
come to be recognized in medical circles during the last 40 years after the French paediatrician, Lemoine
published his 1968 paper entitled, Physical Anomalies Encountered in Children of Alcoholic Women. An
important factor in the study of alcohol consumption during pregnancy is considering what exactly constitutes
the limiting factors of consumption that would compromise fetal development.
The first paper in U.S. medical literature appeared in 1973 authored by Drs David Smith and Ken Lyons
Jones. As of 2012, nearly 4,000 papers have been published confirming the toxicity of alcohol to the embryo or
fetus, the underlying mechanisms of alcohol-induced damage to the embryo or fetus, and the physical and
functional birth defects related to prenatal alcohol exposure.
No published study has suggested that alcohol is not a teratogen or demonstrated that prenatal alcohol use has
any potential benefit to human development.
The basic and biomedical research demonstrates that alcohol damages the developing brain through multiple
actions at different cellular sites interfering with normal development by disrupting cell migration, cell
functions, and causing cell death.
Alcohol can cause damage to multiple regions of the brain, specifically to the corpus collosum (connects brain
hemispheres), cerebellum (consciousness and voluntary processes), basal ganglia (movement and cognition),
hippocampus (emotional behaviour and memory), hypothalamus (sensory input), among other neural regions.
Ethanol is the principal psychoactive constituent in alcoholic beverages. In utero it has been found to:
Impair the development and function of astocytes, cells that guide the migration of nerve cells to their
proper places;
Alter the formation of axons, nerve cell extensions that conduct impulses away from the cell body;
Alter the expression of genes, including genes that regulate cell development.
Human development occurs in an orderly process of biochemical and structural transition during which new
constituents are being formed and spatially arranged throughout gestation. At any time in the span of
development these ongoing processes can be subtly or severely disturbed or abruptly halted resulting in
abnormal development or fetal death.
Therefore, at any time alcohol is present it has the potential to harm development. For example, the hallmark
facial dysmorphology associated with Fetal Alcohol Syndrome will only occur if alcohol is present during the
specific window of development.
Of all the substances of abuse, including marijuana, cocaine and heroin, alcohol produces by far the most
serious neurobehavioral effects on the embryo or fetus.
Abnormal facial features, such as a smooth ridge between the nose and upper lip (this ridge is called the
philtrum)
Shorter-than-average height
Poor coordination
Hyperactive behaviour
Poor memory
Learning disabilities
Clinical Therapy
Antepartum care of the alcohol-abusing woman involves medical, socioeconomic, and legal considerations.
The use of a team approach allows for the comprehensive management necessary to provide safe labor and
delivery for the woman and her fetus.
Appropriate treatment of alcohol withdrawal (AW) can relieve the patients discomfort, prevent the
development of more serious symptoms, and forestall cumulative effects that might worsen future withdrawals.
Hospital admission provides the safest setting for the treatment, although many patients with mild to moderate
symptoms can be treated successfully on an outpatient basis. Severe AW requires pharmacological
intervention. Although a wide variety of medications have been used for this purpose, clinicians disagree on
the optimum medications and prescribing schedules. The treatment of specific withdrawal complications such
as delirium tremens and seizures presents special.
(e.g., alcoholic hepatitis), pancreatic disease (i.e., alcoholic pancreatitis), infectious diseases (e.g.,
tuberculosis), bleeding within the digestive system, and nervous system impairment. Vital signs (e.g., heartbeat
and blood pressure) should be stabilized and disturbances of water and nutritional balances corrected. The
presence of water in the blood problems and requires further research.
progress to questions about alcohol consumption and finally to questions focusing on past illicit drug use. The
nurse who is matter-of-fact and non-judgemental is more likely to elicit honest responses. Formalized alcohol
questionnaires can be used to screen targeted at risk groups. The T-ACE questionnaire has been validated and
appears to be accurate in detecting women who drink more than 1 oz. absolute alcohol per day (approximately
25 g or 2.5 units). Screening is most sensitive for women interviewed during the first 15 weeks of pregnancy.
T-ACE is an acronym from the following:
T TOLERANCE: How many drinks does it take to make you feel high?
A ANNOYED: Have people ANNOYED you by criticizing your drinking?
C CUT DOWN: Have you felt you ought to CUT DOWN on your drinking?
E EYE OPENER: Have you ever had a drink first thing in the morning?
The scoring of the test is straight forward. If answer to the Tolerance question is more than 2, a score of 2 is
given, and a score of 1 is assigned to a positive answer in all others. A total score of more than 2 is considered
positive for problem drinking and this correctly identifies over 70% of heavy drinkers during pregnancy.
An alternative is the Leeds Dependency Questionnaire (LDQ) which is a 10-item, self- completion
questionnaire designed to measure dependence on a variety of substances. It has been shown to be understood
by users of alcohol and opiates. The questionnaire has advantages as it is sensitive to change over time through
the range from mild to severe dependence. The test-retest reliability was found to be 0.95
Biochemical markers blood gamma-glutamyl transferase, alcohol concentration and the thiocyyanate and mean
corpuscular volume can be used as surrogates of excessive alcohol consumption, but they are not accurate and
can only be used as pointers to potential at risk women.
Nursing assessment of the woman who is known to abuse alcohol focuses on her general health status, with
specific attention to nutritional status, susceptibility to infections, and evaluation of all body systems. The
nurse must also assess the womans understanding of the substance abuse on herself and her pregnancy. Some
women are reluctant to discuss their alcohol abuse while others are quite open about it. Once the nurse
establishes a relationship of trust, the nurse can gain information to use in planning the womans ongoing care.
Nursing Diagnoses
Alcohol, a central nervous system depressant, is used socially in our society for many reasons: to enhance the
flavour of food, to encourage relaxation and conviviality, for celebrations, and as a sacred ritual in some
religious ceremonies. Therapeutically, it is the major ingredient in many OTC/prescription medications. It can
be harmless, enjoyable, and sometimes beneficial when used responsibly and in moderation.
It is rapidly absorbed from the stomach and small intestine into the bloodstream. On the other hand, alcohol
withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every
day suddenly stops drinking alcohol.
Alcohol withdrawal symptoms usually occur within 8 hours after the last drink, but can occur days later.
Symptoms usually peak by 24 72 hours, but may persist for weeks. Common symptoms include: anxiety or
nervousness, depression, fatigue, irritability, jumpiness or shakiness, mood swings, nightmares and not
thinking clearly.
Blood alcohol/drug levels: Alcohol level may/may not be severely elevated, depending on amount
consumed, time between consumption and testing, and the degree of tolerance, which varies widely. In the
absence of elevated alcohol tolerance, blood levels in excess of 100 mg/dL are associated with ataxia; at
200 mg/dL the patient is drowsy and confused; respiratory depression occurs with blood levels of 400
mg/dL and death is possible. In addition to alcohol, numerous controlled substances may be identified in a
poly-drug screen, e.g., amphetamine, cocaine, morphine, Percodan, Quaalude.
CBC: Decreased Hb/Hct may reflect such problems as iron-deficiency anaemia or acute/chronic GI
bleeding. WBC count may be increased with infection or decreased if immunosuppressed.
Liver function tests: LDH, AST, ALT, and amylase may be elevated, reflecting liver or pancreatic
damage.
Nutritional tests: Albumin is low and total protein may be decreased. Vitamin deficiencies are usually
present, reflecting malnutrition/malabsorption.
Other screening studies (e.g., hepatitis, HIV, TB): Depend on general condition, individual risk
factors, and care setting.
Urinalysis: Infection may be identified; ketones may be present, related to breakdown of fatty acids in
malnutrition (pseudodiabetic condition).
Chest x-ray: May reveal right lower lobe pneumonia (malnutrition, depressed immune system,
aspiration) or chronic lung disorders associated with tobacco use.
ECG: Dysrhythmias, cardiomyopathies, and/or ischemia may be present because of direct effect of
alcohol on the cardiac muscle and/or conduction system, as well as effects of electrolyte imbalance.
Addiction Severity Index (ASI): An assessment tool that produces a problem severity profile of the
patient, including chemical, medical, psychological, legal, family/social, and employment/support aspects,
indicating areas of treatment needs.
Nursing priorities
1.
2.
3.
4.
5.
Discharge goals
1.
Homeostasis achieved.
2.
Complications prevented/resolved.
3.
4.
5.
6.
1. Anxiety/Fear
Nursing Diagnosis
Anxiety/Fear
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Intervention
Rationale
on an ongoing basis.
Reduces stress.
Reorient frequently.
diazepam (Valium);
controlled setting
and
Sensory-Perceptual Alterations
May be related to
Chemical alteration: Exogenous (e.g., alcohol consumption/sudden cessation) and endogenous (e.g.,
electrolyte imbalance, elevated ammonia and BUN)
Sleep deprivation
Possibly evidenced by
Bizarre thinking
Fear/anxiety
Desired Outcomes
Nursing Intervention
Rationale
deficits.
such as hyperactivity,
disorientation, confusion,
sleeplessness, irritability.
unless necessary.
Note onset of hallucinations.
to patient. Visual hallucinations occur more at night and often include insects,
and tactile.
possible.
whenever possible.
influence.
external stimuli.
aggravate hallucinations.
Cessation of alcohol intake with varied autonomic nervous system responses to the systems suddenly
altered state
Desired Outcomes
Nursing Intervention
Rationale
death.
needed.
Provide for environmental safety when indicated.
Thiamine;
Magnesium Sulfate.
There is no safe amount or type of alcohol to consume during pregnancy. Any amount of alcohol,
even if its just one glass of wine, passes from the mother to the baby. It makes no difference if the
alcohol is wine, beer, or liquor or distilled spirits (vodka, rum, tequila, etc.)
A developing baby cant process alcohol. Developing babies lack the ability to process alcohol with
their liver, which is not fully formed. They absorb all of the alcohol and have the same blood alcohol
concentration as the mother.
Alcohol causes more harm than heroin or cocaine during pregnancy. The Institute of Medicine
says, Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by
far the most serious neurobehavioral effects in the fetus. No type of alcohol or illicit drugs consumed
during pregnancy is completely without risk.
Alcohol used during pregnancy can result in FASD. An estimated 40,000 newborns each year are
believed to have an FASD, Fetal Alcohol Spectrum Disorders, with damage ranging from major to
subtle.
1 in 100 newborns in the U.S. might have FASD, nearly the same rate as Autism. FASD is more
prevalent than Down Syndrome, Cerebral Palsy, SIDS, Cystic Fibrosis, and Spina Bifida combined.
Alcohol use during pregnancy is the leading preventable cause of birth defects, developmental
disabilities, and learning disabilities.
Bibliography
Davidson. M.R., London, M., Ladewig, P.W., (2012). Maternal-newborn nursing and womens
healthcare. 9th Ed. USA: Pearson Prentice Hall.
James, D. K., Steer, P. J., Weiner, C.P. & Gonik, B., (1999). High Risk Pregnancy Management
Options. 2nd Ed. London, United Kingdom: Harcourt Brace and Company
Varney, H., Kriebs, J., Gegor, C., (2004) Varneys Midwifery. 4th Ed. USA: Jones and Bartlett
Publishers.
.