[CG] Alcohol in pregnancy guideline for obstetric management
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Applicable Unit policies
- Use of alcohol and other drugs in pregnancy (use of opiates, use of benzodiazepines) guidelines for management
- Use of alcohol and other drugs in pregnancy guideline for management flow chart
Identification of use of alcohol above recommended limits use in pregnancy
Taking of detailed history of alcohol consumption and identification of consumption above recommended level is part of the routine antenatal booking history. Women identified as drinking above recommended levels should additionally receive “information and brief advice” (IBA) using the agreed tool.
Inpatient management of alcohol withdrawal
Many patients admitted to hospital have true physical dependence on alcohol. Whether their admission is occasioned by an alcohol-related problem or not, management of the sequelae of alcohol withdrawal will form an important part of overall patient management. Failure to adequately deal with alcohol withdrawal places the patient at risk (from seizures, self-injury etc.) and also represents a significant hazard to hospital staff and other patients who may be at risk of injury or assault from patients suffering from poorly controlled alcohol withdrawal.
Many alcohol-dependent patients will have significant non obstetric pathologies, both acute (e.g. pneumonia, GI bleed) and/or chronic (e.g. liver impairment, cerebral atrophy) and management of alcohol withdrawal needs to consider the possible effects of these other pathologies, which may themselves lead to patients becoming confused, aggressive or even violent.
An assessment of the pattern and level of alcohol consumption should be a routine part of booking history. In the presence of acute intoxication additional information from relatives and friends may be very useful, especially where the patient is unable to give a reliable history. There is a tendency for patients to underestimate their alcohol intake and where the clinical picture points to significant alcohol consumption (e.g. evidence of liver disease, high MCV, elevated GGT etc.) this should be considered in the overall assessment of withdrawal risk. Anyone taking more than 10 units of alcohol per day should be considered "at risk" of experiencing symptoms of alcohol withdrawal.
Practical management of alcohol withdrawal should be as follows:
Certain drugs, most notably the benzodiazepines, have been shown to effectively substitute for alcohol and prevent the development of delirium and / or seizures. All patients experiencing or likely to experience symptoms of alcohol withdrawal should receive diazepam orally (or parenterally if convulsing). The maximum required starting dose in pregnancy is diazepam 10mg three times daily orally and this should be reduced by 5mg daily reducing the 3 doses in rotation with the evening dose last (as for benzodiazepine detoxification).
Whenever possible, diazepam should be commenced before the onset of symptoms of alcohol withdrawal as prevention of acute disturbance is better than its subsequent management. Patients should be observed closely (every 1-2 hours); they may develop symptoms including confusion, agitation, sweating, tachycardia or hallucination (either auditory or visual) but the objective of treatment is prevention of convulsions not symptomatic relief. Always exclude other possible illnesses as a cause of symptoms.
Hepatic impairment will prolong metabolism of diazepam and will therefore prolong the action of the drug. Intravenous diazepam (as Diazemuls®) should be given with caution due to the small risk of apnoea. Intramuscular diazepam is poorly absorbed and should not be used. In very exceptional circumstances additional treatment with a major tranquilliser may be required.
Patients with prolonged heavy alcohol consumption, especially in association with poor diet, are at risk of Wernicke’s encephalopathy and Korsakov’s psychosis. All such patients should receive parenteral thiamine (a component of Pabrinex®) for at least 3 doses at daily intervals, commencing as soon as possible after admission (and before any carbohydrate is given orally or intravenously). Note that thiamine does NOT influence the development of typical symptoms of alcohol withdrawal.
1. The avoidance of convulsions of alcohol withdrawal is an important part of management of susceptible patients.
2. ALL susceptible patients must be assessed on admission to gauge the risk of convulsions.
3. Susceptible patients must be assessed regularly (every 1-2 hours).
4. Diazepam alone is the appropriate treatment for prevention of convulsions and additional treatment with a major tranquilliser will only be required in very exceptional circumstances.
Additional Obstetric Care
1. All women using alcohol above recommended limits should be offered a fetal anomaly scan (FAS) at 20 weeks gestation according to protocol.
2. In addition, in women using alcohol above recommended limits, should be offered serial growth scans in 3rd trimester
3. Record use of alcohol and other drugs (illicit and / or prescribed) on yellow alert sheet (maternal and neonatal sections) in maternal case notes.