Pregnant
Pregnant
Nonpregnant
Nonpregnant
Characteristic
Any use %
Binge drinking %
Any use %
Binge drinking %
Total
11.2
1.8
54.6
12.6
Age group in years
18–24
8.6
2.5
55.5
19.6
25–34
11.2
1.4
55.1
12.2
35–44
17.7
1.8
53.6
8.9
Education
High school diploma or less
8.5
1.8
43.1
11.6
Some college
11.2
2.0
57.2
14.4
College degree or more
14.4
1.8
66.3
12.0
Employed
Yes
13.7
2.3
59.1
13.5
No
8.3
1.3
46.1
10.9
Married
Yes
10.2
1.1
52.6
8.4
No
13.4
3.6
56.9
17.6
Race/ethnicity
White/non-Hispanic
11.6
1.8
60.9
14.9
Black/non-Hispanic
10.3
2.1
43.3
6.8
Hispanic (any race)
10.2
1.7
41.1
8.9
Other race (non-Hispanic)
12.1
2.5
46.0
9.7
Women with an unplanned pregnancy had a higher proportion of binge drinking during the preconception period (16 % versus 12 %) in comparison to women with a planned pregnancy. The Canadian Maternity Experiences Survey (2009) indicated that 62.4 % of women acknowledged drinking alcohol 3 months prior to pregnancy. However, only 10.5 % of these surveyed women reported that they continued drinking alcohol while they were pregnant, of which 0.7 % drank two drinks on the day they drank, and 9.7 % drank less than once per week [7].
In 2010, in the United Kingdom, 80 % of the women drank alcohol prior to pregnancy; however, it dropped to 40 %, when they became pregnant. Among women who drank before pregnancy, about 49 % stopped drinking during pregnancy, whereas 46 % cut down on the amount of alcohol. Two percent of women did not change their drinking habits after they knew that they were pregnant [8].
In France, 23–52 % of pregnant women reported they continued drinking during pregnancy, of which 3.4–7.3 % reported at least one binge drinking episode [9]. Thirty percent of pregnant women reported regular alcohol use during pregnancy, of which 9 % reported drinking more than five drinks more than once a month, and 1 % reported drinking more than five drinks at least once a week [10].
Women drinking alcohol early in pregnancy are more likely to be from Caucasian race, have higher education, better socioeconomic status, and single as compared with women who do not drink alcohol early in pregnancy [8, 11]. Women who continue drinking alcohol during pregnancy are more likely to be from African-American origin and use other recreational drugs.
7.4.2 What Is Internationally Meant by a “Standard Drink”?
Different types of alcoholic beverages, such as beer, wine, malt, whiskey, etc., contain different alcohol percentages. For healthcare givers and patients, it is essential to know what a standard drink constitutes so that one might be able to understand the impact of alcohol in their national system. The definition of a “standard drink” differs over various countries.
To date, there is no standard convention across countries to define what a “standard drink” is. Most countries do not use standard definitions for drinks, and they are measured by serving sizes, which depend on the local culture and customs. This factor should be taken into account when comparing alcohol use across countries as there is a wide range of alcohol content (8–14 g) in a “standard drink.”
7.4.3 What Is the Definition of Binge Drinking?
Next to the difference in definition of a “standard drink,” the definition of binge drinking also varies from country to country:
-
In the United Kingdom, binge drinking is defined as drinking more than twice the daily recommended unit of alcohol in one session, which is more than six units of alcohol (48 g of alcohol) for women and eight units of alcohol (64 g of alcohol) for men [12].
-
In other European countries, binge drinking is defined as “a single drinking session,” which includes at least 40 g of alcohol for women and 60 g of alcohol for men within a 2-h period [5].
-
In the United States, the National Institute of Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as a pattern of drinking alcohol that brings the blood alcohol concentration (BAC) to more than 0.08 g/l or above, which corresponds to 56 g or more for females and 70 g or more for males in a 2-h period [4].
7.4.4 What Is the Difference Between Men and Women Drinking Alcohol?
When a woman and a man drink the same amount of alcohol, of the same type of drink, the alcohol concentration in a woman is higher compared to a man at that given time, because women have less body water and more fat compared to men of the same body weight [13]. Moreover, women have lower activity of alcohol dehydrogenase, the enzyme that breaks down alcohol, resulting in higher alcohol percentages in women compared to men.
7.4.5 Why Are People Drinking Alcoholic Beverages?
In most cultures, drinking alcohol is a socially accepted norm, as the expected immediate effect of alcohol is reduction in social anxiety, becoming more sociable, and developing a positive mood, with a sense of euphoria [14]. However, people who go through some form of psychological distress, which could be secondary to physical, sexual, or emotional trauma, may more easily become dependent on alcohol. Alcohol will numb their feelings so that they do not have to face the psychological distress, which may create a vicious cycle. Both the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD–10) [15], and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5) [16], have defined criteria for harmful use of alcohol. In Table 7.2, the criteria of ICD-10 are depicted.
Table 7.2
International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) definition of harmful use of alcohol
|
ICD-10 definition of harmful use of alcohol | |
|
Clear evidence that alcohol use contributed to physical or psychological harm, which may lead to disability or adverse consequences
The nature of harm should be clearly identifiable
The pattern of use has persisted for at least 1 month or has occurred repeatedly within a 12-month period
Symptoms do not meet criteria for any other mental or behavioral disorder related to alcohol in the same time period (except for acute intoxication) | |
|
Criteria for alcohol dependence: three or more of the clustering criteria, occurring together for at least 1 month or if less than a month, occurring together repeatedly within a 12-month period | |
|
1 |
Need for significantly increased amounts of alcohol to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount of alcohol, also defined as tolerance |
|
2 |
Physiological symptoms characteristic of the withdrawal syndrome for alcohol or use of alcohol to (or closely related substances) to relieve or avoid withdrawal symptoms |
|
3 |
Difficulties in controlling drinking in terms of onset, termination, or levels of use: drinking in larger amounts or over a longer period than intended or a persistent desire or unsuccessful efforts to reduce or control drinking |
|
4 |
Important alternative pleasures or interests given up or reduced because of drinking |
|
5 |
Great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking |
|
6 |
Persisting with drinking despite clear evidence and knowledge of harmful physical or psychological consequences |
|
7 |
A strong desire or sense of compulsion to drink |
|
Duration criterion | |
|
Three or more of dependence criteria occurring for at least 1 month or if less than 1 month, occurring together repeatedly within a 12-month period | |
7.5 Etiology and Pathogenesis
7.5.1 How Is Alcohol Metabolized and Transferred to the Fetus?
Alcohol is metabolized to acetaldehyde by the alcohol dehydrogenase, which is then oxidized to acetic acid by acetaldehyde dehydrogenase. Alcohol and acetaldehyde freely enters the fetal circulation through the placenta. Since the fetal alcohol dehydrogenase is less active compared to the maternal alcohol dehydrogenase, alcohol stays in the fetal circulation for a longer period of time compared to the length of stay in maternal circulation [1].
7.5.2 What Are the Teratogenic Effects of Alcohol Use in Pregnancy?
Alcohol and its primary metabolite acetaldehyde are teratogenic. Although it is universally accepted that alcohol is a teratogen, there is a general lack of consensus regarding the safe level of alcohol consumption during pregnancy, which is reflected by varying policies on safe amount of alcohol consumption while pregnant throughout the world.
Fetal development is a multistage, sequential process. Exposure at any given time will affect the organ or system that is developing at that time. The effect on each developing system or function is related to the dose of exposure [11]. The teratogenic effect of prenatal alcohol use depends on the nutritional status of the pregnant women, on how much and how often the alcohol intake was spread out over a period of time, the role of binge drinking, and the gestational period during which alcohol was consumed. Alcohol exposure early in pregnancy causes major morphological defects and growth restriction with alcohol exposure to the latter part of pregnancy. Neurodevelopmental deficits occur with alcohol exposure throughout pregnancy. Therefore the deficits might not be the same for a newborn being exposed to alcohol throughout pregnancy compared to a newborn exposed to alcohol during specific periods of gestation.
A prospective study from the United Kingdom found a statistically significant (p < 0.05) increased risk of preterm, low birth weight, and lower birth percentile babies in pregnant women who had taken less than two units of alcohol during their first trimester. Third trimester exposure to alcohol is associated with reduced brain weight to body weight ratio, also called microcephaly [17].
7.5.2.1 Fetal Alcohol Spectrum Disorder (FASD) and Fetal Alcohol Syndrome (FAS)
Children who were exposed to alcohol prenatally, throughout the whole gestational period [14], may develop fetal alcohol spectrum disorder (FASD). In FASD, a varying degree of neurobehavioral disturbances may be seen with deficits in verbal learning, spatial memory and reasoning, reaction time, balancing, and other motor skills. These children are found to have issues with mental health later in their life, as they have varying degree of social awkwardness. The most severe end of this disorder is called fetal alcohol syndrome (FAS). Children with FAS usually are small for their age, with characteristic facial anomalies and central nervous system deficits. The Birth Defects Monitoring Program reports a prevalence of 5.2 children with FAS for every 10,000 live births [18]. These children are characterized by growth deficiency (height or weight ≤10th percentile), unique facial anomalies, such as short palpebral fissure, short mid face, etc. (Fig. 7.1) [19], and severe central nervous system deficits including mental retardation [11].
Fig. 7.1
Characteristics of fetal alcohol syndrome in young child (based on, with permission, Streissguth and Bonthius [19])
7.5.3 Why Is It Important to Identify Women Drinking Alcoholic Beverages During Pregnancy?
As there is an increased association between prenatal alcohol exposure and the risk of developing neurobehavioral teratogenicity in the fetus, it is of utmost importance to identify these women on various levels. Early intervention in these pregnant women might reduce or stop further alcohol use while they are pregnant. This in turn reduces the possible exposure of the fetus to alcohol, thereby minimizing the damage to the growing brain of the fetus. Identifying alcohol use later in pregnancy or even after the baby is born helps with identifying high-risk infants, who can be closely monitored for alcohol-related neuroteratogenic issues, providing them with increased support at school and stable living arrangement with or without special services as deemed appropriate.
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