Identifying the Pregnant Women Who Drink
The expectant mother you see
in your practice
may be a nondrinker; she may have had a little to drink recently
and is worried about it; or she may be a regular or heavy drinker
and not fully aware of the dangers to her baby. A few basic questions
will help you identify the possible risk-drinker and provide her
with the information-and the help that she needs.
Identify risk-drinkers:
Exploratory questions
Information about the use of tobacco, drugs,
and alcohol
is usually included in the "social history"
portion of a woman's intake history and physical. Questions about
alcohol consumption, however, are often neglected or asked in a
manner that conveys a lack of concern-which may frequently be true,
since alcohol problems are not considered "medical" by
many physicians. Often, aware of the stigma associated with heavy
drinking, physicians are afraid to evoke anger from patients if
they delve too deeply into drinking behavior.
Nonetheless, there are ways to get at the patient's
drinking history
that can be comfortable for both the patient
and the physician. The first place to start may be by asking whether
there is any family history of alcohol problems (Table 1). Beside
providing useful information about alcoholism, a disease now recognized
as having an important genetic component, asking about the family
history indicates that drinking alcohol is an important concern
and one of interest to the physician who is caring for the family.
If you do not have an opportunity to see the
mother before the baby is born
, you can ask about family history
at the first newborn visit. If you elicit a family history of heavy
alcohol consumption, you create an opportunity to explore the topic
at successive newborn visits. Certainly if the mother comes to these
visits with evidence of an "alcoholic fetor"-symptoms
of battering or symptoms in the newborn of child abuse or neglect,
you would want to explore the subject of alcohol consumption in
greater detail.
After obtaining other "social history"
information
, we return to the alcohol history by asking the
mother if she has ever had a drink of alcohol. If her answer is
"No", that is all that is necessary since it is unlikely
that she has an alcohol problem. If she responds "Yes",
ask how old she was when she first had a drink of alcohol. In most
cases, this will be sometime during the teenage years. Then ask
what she preferred as a teenager-beer, wine, or liquor-and how old
she was when she first got drunk. This query conveys the notion
that you recognize inebriation as a common experience and that admitting
that one has been drunk is "OK."
After establishing a level of
comfort in the interview, move on to a few key questions:
-
How many drinks
did it take to make you feel high when you were a teenager?
-
What is you current alcohol preference
(beer, wine, liquor)?
-
How many cans
(glasses) of beer (wine,
liquor) does it take to make you feel high now?
It appears that
eight or nine out of ten people
will indicate that they feel high
after a maximum of two drinks-two
cans of beer, glasses of wine, or mixed drinks, all of which contain
about the same amount of absolute alcohol. If a patient says it
takes more than two drinks to make her feel high, her drinking behavior
needs further exploration. Seeking evidence of alcohol tolerance
seems more effective in obtaining an alcohol consumption history
than merely asking a patient how much she drinks. Denial is a large
component of alcohol dependence and abuse.
Some useful screening tests
Since a reliable laboratory test has not yet
been developed
to identify risk-drinkers, formal questionnaires
have been devised to aid in identifying this group. The gold standard
questionnaire has been the Michigan Alcoholism Screening Test (MAST),
a 25-question instrument that is widely used in alcohol research.
Recognizing that the clinician does not have the time or office
staff to administer such a test, a number of simpler, briefer questionnaires
have been developed recently. The efficacy of these mini questionnaires
has not been widely evaluated among pregnant women, but they do
appear to hold some promise.
One such test is the CAGE questionnaire
(Table
2). When this test was compared with the MAST in 1,497 consecutive
new registrants at a prenatal clinic, the CAGE test successfully
identified five or six out of ten risk-drinkers (Bottoms, Sokol
& Martier 1988). Although the CAGE misses nearly half of risk-drinkers,
the test offers a very simple screening technique. It takes just
30 seconds to one minute to administer, is reasonably efficient,
and fits well into many clinical settings.
To improve the sensitivity of the CAGE questionnaire
,
the T-ACE screening test was developed through stepwise discriminative
analysis of the responses of 971 pregnant risk-drinkers and 929
pregnant women who were not at risk (Sokol, Martier & Ager,
1989). In the CAGE and T-ACE tests, three of the four questions
are the same; the key difference is that the T-ACE includes a question
on alcohol Tolerance (How many drinks does it take to make you feel
high?).
When none of the answers to the T-ACE questions
are positive,
the probability that an individual is a risk-drinker
is 1.5%. If the patient states that it takes more that two drinks
to feel "high," this answer alone increases the probability
of risk-drinking 8.5-fold, to 11.7%. If all four questions are answered
positively, there is a 62.7% likelihood of risk-drinking. A score
of 2 is assigned to the Tolerance question and a score of 1 to all
the others. A T-ACE score of 2 or more is considered positive for
risk-drinking, indicating the need to pursue the history of alcohol
consumption in greater detail.
When compared with other questionnaires, including
the MAST,
the T-ACE appears to be superior, identifying seven
out of ten risk-drinkers during pregnancy
. The crucial question
appears to be the one on tolerance, which resists the denial component
inherent in the problem drinking.
These preliminary findings need further verification
and possible adjustment to socioeconomic status and racial composition
.
T-ACE may be used in most clinical practices. It holds great promise
for better risk identification, prevention efforts, and improved
pregnancy outcomes for offspring at risk of heavy prenatal alcohol
exposure.
Suggesting Interventions
Clinicians frequently wonder about their role
in intervening to reduce maternal alcohol consumption. It is clear
that warnings by physician's can make an impact on reducing alcohol
intake in many. Counseling heavy drinkers may require more time
than many busy pediatricians, obstetricians, family practice physicians,
and other medical providers are able to provide, but ignoring these
women may result in marked morbidity in the newborn. A team approach
involving a psychiatrist, psychologist, and other psychosocial workers
may improve the outcome in these cases. These health-care providers
are often linked with local Alcoholic Anonymous chapters or other
support groups.
The pediatrician may also be approached by women
fearing
that they have "damaged" their fetus by consuming
alcohol early in their pregnancy. In some cases, since decreased
fetal growth is a major component of FASD, serial ultrasound many
be beneficial in suggesting growth abnormalities.
The majority of FASD infants are born to
chronic,
heavy alcohol users, a group of women who rarely seek counseling
or prenatal care. A lack of prenatal care and failure to keep pediatric
appointments may be red flags that suggest the need to further assessment.
Educating mothers about the dangers of alcohol
consumption is an important part of prenatal and newborn care. A
number of brochures and other helpful materials are available.
The value of screening
efforts
Alcohol is a human teratogen capable of producing
a variety of defects
ranging from [spontaneous] abortion and
stillbirth to birth defects that are less easily identified. Most
physicians lack the formal medical training necessary to recognize
the risk-drinkers in their practice. However,
there are some
basic screening techniques that can be used to identify risk-drinkers
in the clinical setting. The results of these techniques many lead
to secondary prevention efforts and improved pregnancy outcomes
for the offspring at risk of FASD and alcohol-related birth defects.
TABLE 1
Preliminary questions to
ask
-
Is there a family history of alcohol problems
(Indicates that drinking is an important concern to patient and
physician.)
-
Have you ever had a drink of alcohol?
-
If Yes:
-
How old were you
when you had your
first drink?
-
What drink
did you prefer as a teenager
(beer, wine, liquor)?
-
How old
were you when you first got
drunk?
-
How many drinks
did it take to make
you feel high when you were are teenager?
-
What's your current
alcohol preference
(beer, wine, liquor)?
-
How many cans
(glasses) of been (wine, liquor) does it take to make you
feel high right now?
If a patient indicates that
it takes more that 2 drinks to make her feel high, this suggests
her drinking behavior needs further exploration.
TABLE 2
Mini-questionnaires to use
CAGE questions
C
Have you ever
felt you should
Cut
down on
your drinking?
A
Have people
Annoyed
you by criticizing your
drinking?
G
Have you ever
felt bad or
Guilty
about drinking?
E
Have you ever
taken a drink first thing in the morning (
Eye
opener
) to steady your nerves or get rid of a hangover?
The CAGE test takes no more than 1 minute
to administer and identifies about 50% to 60% of risk-drinkers.
________________________
T-ACE questions
T
How many drinks
does it
Take
to make you feel
high (tolerence)?
A
Have
people
Annoyed
you by criticizing
your drinking?
C
Have you ever
felt you ought to
Cut
down on
your drinking?
E
Have you ever
had a drink first thing in the morning to steady your nerves or
get rid of a hangover (
Eye opener
)?
Scoring: 2 points if answer to T question
is "more than 2 drinks,"
1 point for answering Yes to the A, C, or
E questions.
T-ACE score of 2 or more is considered positive
for risk-drinking. If all 4 questions are answered in the positive,
the likelihood of risk-drinking is 62.7%, if no answers are positive,
the likelihood is 1.5%.2 The test identifies about 7 of 10 risk-drinkers.