the CAGE, Alcohol Use Disorders Identification Test (AUDIT), and the revised AUDIT‐C; however, most of these commonly used tools have not been validated in pregnant populations. The American College of Obstetricians and Gynecologists (ACOG) and the National Institute on Alcohol Abuse and Alcoholism recommend using the T‐ACE or revised TACER‐3 (T‐tolerance, A‐annoyance, C‐cutting down, and E‐eye Opener) screening tools which have been specifically validated for use in pregnant women. Because T‐ACE/T‐ACER‐3 define risky drinking as the consumption of one ounce or more of alcohol per day and identify patterns of use suggestive of AUD, additional questions must be used to assess for the use of any alcohol.
Another option is the Substance Use Risk Profile–Pregnancy (SURP‐P), which was designed specifically to screen for alcohol and other illicit/recreational drug use in pregnancy. The SURP‐P is easily administered and consists of three questions: 1) Have you ever smoked marijuana? 2) In the month before you knew you were pregnant, how many beers, how much wine, or how much liquor did you drink?, and 3) Have you ever felt that you needed to cut down on your drug or alcohol use? Scoring requires tallying the number of affirmative responses (0 = low risk, 1 = moderate risk, 2–3 = high risk).
Screening for alcohol use during pregnancy allows clinicians to stratify risk in women according to their patterns of use. It is recommended that women at low risk should receive brief counseling regarding the risk of alcohol use during pregnancy. Women classified as moderate risk should receive a brief intervention (described below), and women at high risk should be referred for specialized substance abuse treatment.
Providers must also be aware of the possibility of concurrent psychiatric illness, as women with risky alcohol use are more likely to suffer from psychiatric illness, and women with untreated psychiatric illness are more likely to use alcohol (and other substances) during pregnancy. Consultation with mental health professionals is indicated and attending to co‐morbid psychiatric illness can increase the likelihood of abstinence during pregnancy and improve compliance with prenatal care.
Intervention and referral to treatment
Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive, integrated public health approach used to identify and deliver services to those at risk for substance use disorders and has the potential to reduce the burden of substance use in pregnancy. SBIRT may be implemented in a variety of healthcare settings and adapted for culturally diverse populations. The Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) provides many useful materials to facilitate implementation of SBIRT which consists of three basic components.
1 Screening by a health professional using validated instruments can quickly assess the severity of substance use and identify the appropriate level of care.
2 Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
3 Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.
After screening, women at moderate risk should receive a brief intervention which typically involves counseling sessions, approximately five minutes in length, tailored to the severity of the identified alcohol problem. During the first meeting, the provider should state her/his concerns and help to set goals. Educational materials should be provided. Routine follow‐up is essential; subsequent visits should involve encouragement, information, and reevaluation of goals. Wright and colleagues (Table 1.1) have modified SBIRT for use in pregnant women, leveraging the motivation inherent in the desire to have a healthy pregnancy.
Table 1.1 Four components of brief intervention
Source: Wright et al. (2016). © 2016 Reproduced with permission of Elsevier.
| Raise subject | “Thank you for answering my questions – is it OK with you if we talk about your answers?” “Can you tell me more about your past/current drinking or drug use? What does a typical week look like?” |
| Provide feedback | “Sometimes patients who give similar answers are continuing to use drugs or alcohol during their pregnancy.” “I recommend all my pregnant patients not to use any alcohol or drugs, because of the risk to you and to your baby.” |
| Enhance motivation | “What do you like and what are you concerned about when it comes to your substance use?” “On a scale of 0–10, how ready are you to avoid drinking/using altogether? Why that number and not a lower number?” |
| Negotiate plan | Summarize conversation. Then: “What steps do you think you can take to reach your goal of having a healthy pregnancy and baby?” “Can we schedule a date to check in about this next time?” |
Women who are unable to reduce or eliminate consumption of alcohol during pregnancy should be referred for more intensive intervention.
Conclusion
Alcohol consumption during pregnancy is relatively common, with the most recent surveys indicating that 11.5% of pregnant women in the US report consuming alcohol during pregnancy. While heavy alcohol use and binge drinking pose the greatest risk to the fetus, lower levels of exposure to alcohol have been associated with birth defects, neurodevelopmental deficits, and fetal alcohol spectrum disorders. OB‐GYNs are ideally positioned to screen women for risky alcohol use both before and during pregnancy and can educate women regarding the risks of alcohol use during pregnancy and initiate interventions which significantly decrease the use of alcohol during the perinatal period.
Suggested reading
1 American College of Obstetricians and Gynecologists' Committee on Health Care for Underserved Women. Committee Opinion No.654: Reproductive Life Planning to Reduce Unintended Pregnancy. Obstet Gynecol 2016; 127(2):e66–9.
2 Brown RA, Dakkak H, Seabrook JA. Is breast best? Examining the effects of alcohol and cannabis use during lactation. J Neonatal Perinatal Med 2018; 11(4):345–56.
3 Denny CH, Acero CS, Naimi TS, Kim SY. Consumption of alcohol beverages and binge drinking among pregnant women aged 18–44 years – United States, 2015–2017. MMWR 2019; 68(16):365–8.
4 DeVido J, Bogunovic O, Weiss RD. Alcohol use disorders in pregnancy. Harv Rev Psychiatry 2015; 23(2):112–21.
5 Subramoney S, Eastman E, Adnams C, Stein DJ, Donald KA. The early developmental outcomes of prenatal alcohol exposure: a review. Front Neurol 2018; 9:1108.
6 Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G, Creanga AA. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol 2016; 215(5):539–47.
PROTOCOL 2 Smoking, Vaping, and Nicotine Exposure
John Byrne1 and George Saade2
1 Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
2 Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Medical Branch,
