| Home Page | MCQ Paper 5 | Sample MCQs |
| a. | affects one fetus in 100 | False |
| b. | at risk mothers are usually identified antenatally | False |
| c. | is associated with a 50% risk of mental retardation | True |
| d. | the affected fetus often shows macrosomia | False |
| e. | the incidence of major cardiac malformation increases | True |
| f. | is particularly associated with facial malformation | True |
| g. | is associated with microcephaly | True |
| h. | mothers who drink heavily have an increased risk of miscarriage | True |
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ARND: alcohol-related neurodevelopment disorder.
ARBD. alcohol-related birth defects.
CDT: carbohydrate-deficient transferrin.
FBC: full blood count.
GGT: gamma glutamyl transpeptidase
DOH: Department of Health
FAS: fetal alcohol syndrome.
MCV: mean corpuscular volume
NICE: National Institute for Health and Clinical Excellence
RCOG: Royal College of Obstetricians and Gynaecologists
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Fetal Alcohol Syndrome.
The baby has the physical features of FAS (see below).
And a variety of neuro-developmental problems.
Alcohol-Related Neurodevelopment Disorder.
The baby has neuro-developmental problems.
But not the physical abnormalities.
Alcohol-Related Birth Defects. ARBD.
The American Academy of Pediatrics also recognizes “Alcohol-Related Birth Defects”.
These are linked birth defects.
The babies may have neurological or developmental problems.
But not necessarily.
I don’t think this will feature in the DRCOG.
The College is only just catching up with FAS and ARND.
And is still issuing what I regard as lousy advice about drinking in pregnancy!
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Alcohol is teratogenic and toxic to the developing fetus.
It is linked to increased rates of:
miscarriage,
IUGR,
fetal death-in-utero
premature delivery,
stillbirth,
microcephaly,
low IQ,
neuro-development disorders,
attention-deficit disorders,
cardiac and renal abnormalities,
reduced growth in childhood:
children are lighter even in their teenage years.
Binge-drinking (>5 units) is probably a major risk factor.
Binge-drinking also increases the risk of sexually transmitted disease and unplanned pregnancy.
FAS and ARND are not easy to diagnose - more training needed.
High alcohol-intake is linked to other risk factors:
low maternal folate levels,
smoking,
other drugs,
low socio-economic status etc.
For the exam, use the RCOG advice of maximum intake of “one or two units once or twice a week”.
In real life, advise abstinence for those pregnant or who could become pregnant.
The DOH advocated zero alcohol in pregnancy in May 2007.
Unfortunately, it gave a confusing message. - see below.
We need better identification of those drinking in pregnancy. (See MCQ 11, question 14.)
Ideally we need a biochemical screening test.
Easy access from ante- natal clinics to treatment facilities.
Further research is needed.
Alcohol is also linked to infertility and disturbances of the menstrual cycle.
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Expanded information for the MRCOG and to help facts stick.
Read the "Key facts for the DRCOG" section first.
List of contents in this section.
folic acid and alcohol consumption
Inadequate attention is paid to this disorder.
Alcohol is now seen to be a potent teratogen and fetal toxin.
High intakes and binge drinking (more than five units at a time) are thought to be particularly risky.
There are good grounds for anticipating more affected babies:
alcohol consumption among young women is high,
binge-drinking among young women is common,
most pregnancies are unplanned,
so these women will continue to drink in the early weeks.
Low level consumption may carry no risk.
But no safe level has been identified below which harm cannot occur.
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I hope that this web page gives you all you need.
But you can expand your reading with the web pages below.
RCOG Statement No 5, "Alcohol Consumtion and The Outcomes of Pregnancy".
Fetal alcohol spectrum disorders: BMA Board of Science.
A detailed article in emedicine.
March of Dimes article.
Some pictures to help facts stick here.
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There is evidence that FAS and ARND make up the leading non-genetic cause of mental retardation.
Incidence of FAS varies but has been estimated at about 3 per 1000 in the United States.
With ARND affecting many more.
This means about 1 baby in every 100 having some alcohol related damage.
This is horrifying!
The figures for the UK are lower but uncertain.
The higher American figures are attributed to higher alcohol consumption by the black and native Indian populations.
I am unsure about how valid this is.
The incidence of the full-blown syndrome in women with severe alcohol dependence was assessed at 4 – 5% by Gray & Henderson in 2006. (Review of the fetal effects of prenatal alcohol exposure. National Perinatal Epidemiology Unit, University of Oxford.)
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The full syndrome includes:
short stature,
the classical facial features-
short palpebral fissures (the openings between the eyelids),
flat philtrum (the area between nose and upper lip – usually grooved),
thin upper lip vermilion - the red, mucosal area of the lip,
neurocognitive problems etc.
Microcephaly is reported in more than 50%.
The American Academy of Pediatrics says > 80%.
It is mild to moderate in most cases and may only be obvious on formal measurement.
The IQ is < 70 in a similar percentage.
Cardiac and renal malformations are common.
IUGR is commonplace, not macrosomia.
Many will look normal but have hyperactivity, difficulties with mental organisation, delinquent behaviour etc.
These overlap with other conditions such as hyperactivity syndrome, personality disorder and autism.
As a result, the true diagnosis may be missed.
On the other hand, it has been pointed out that babies of alcoholic mothers could have other syndromes.
They should not be assumed to have FAS or ARND if they have suggestive symptoms.
Individuals with high alcohol consumption are low in folate, with implications for neural tube defects.
There is evidence of an increased rate of spina bifida.
The risk of miscarriage is several times higher than the normal.
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Is there a safe lower level of maternal alcohol consumption below which there is no risk?
Low level consumption may be safe, but there is no cut-off below which there is a guarantee of no risk.
My advice is abstinence for:
those who are pregnant,
those trying to conceive,
and those not using reliable contraception.
This is especially so as women may think they are taking safe amounts.
But, in fact, are likely to be taking much more – see below.
There was a nice leader in the BMJ of the 19th. February 2005 on low level alcohol consumption and the fetus.
Worth a read.
It concluded that there was no safe level of consumption as far as the fetus was concerned.
Let us imagine that a safe level of alcohol consumption existed.
And that pregnant women tried virtuously to adhere to it.
The BMJ editorial quoted a worrying study by Kaskutas & Graves.
In this women poured themselves drinks that they thought were standard measures.
These proved to be up to 3 times greater than true standard measures!
The study was done in America, but similar results would be likely in the UK.
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Folic acid and alcohol consumption.
Excessive alcohol intake leads to reduced blood folate levels.
This could have implications for the developing fetus.
It is important to ensure that women take folic acid supplements.
Some sources even say to up the dosage to 5mg. daily.
I think for the exam you would get the mark just for mentioning it.
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Public health advice on alcohol and pregnancy.
The advice in America from the Surgeon General is complete abstinence.
No equivocation or qualification, unlike the UK.
Alcohol products in the USA have warnings on their labels about the dangers of taking alcohol in pregnancy.
This has been so for more than twenty years.
In the UK the advice is roughly that:
abstinence is best,
that binge-drinking and getting drunk are bad,
but that there is no evidence of harm from “low level” consumption.
"Low level" being “no more than one or two units of alcohol once or twice a week”.
NICE advocates abstinence in the first trimester because of the risk of miscarriage.
The Department of Health "strengthened" its advice in May 2007.
It advised that women should avoid alcohol if pregnant or trying to become pregnant.
Unfortunately it added the confusing advice that:
“women who do choose to drink, before and during pregnancy,
should drink no more than one to two units of alcohol once or twice a week”.
The advice was updated in June 2009 and now reads:
“When you drink, alcohol reaches your baby through the placenta.
But the baby can't process it as fast as you can.
So it is exposed to greater amounts of alcohol for longer than you are.
Which can seriously affect the baby's development.
Pregnant women or women trying to conceive should avoid drinking alcohol.
If they do choose to drink, to protect the baby:
they should not drink more than 1-2 units of alcohol once or twice a week,
and should not get drunk.
Click here to go to the relevant DOH web page.
There is also a DOH leaflet that covers alcohol in relation to trying to get pregnant, pregnancy and breast-feeding.
Note the peculiar NICE advice mentioned above that alcohol should be avoided in the 1st. trimester because of the risk of miscarriage.
Click here to go to the NICE document, "CG62 Antenatal care".
The RCOG responded to the DOH's updated advice as follows:
"Abstinence from alcohol is the safest option.
However, the prevailing RCOG advice remains
low level consumption of alcohol (1 or 2 units once or twice a week)
has not yet been found to be harmful to women or their babies".
Note the "yet".
You can find the RCOG's response here.
Read the RCOG web page intended for the public.
Read the RCOG Statement No 5: "Alcohol consumption and the outcomes of pregnancy".
I don’t like the UK advice and think it is stupid.
If the message is abstinence, that should be the message.
And it should be undiluted - is that a Freudian slip by a whisky drinker?
Adding stuff about what might be a safe upper limit merely diminishes this key message.
It sounds as though abstinence is OK for saints, but mere mortals can make do with moderate intakes.
And it is open to dangerous misinterpretation.
"One or two" is not usually said as a matter of arithmetical precision.
E.g. one might say: “We had one or two friends round for dinner at the weekend”, meaning six or eight.
So, "one or two" could mean almost anything.
A woman following this advice might reasonably think that:
"one or two"drinks, in reality four or five,
"once or twice" a week, in reality four or five times,
was following the College’s advice.
Even the woman who virtuously limited herself to two drinks twice a week would still be at risk.
Research has shown that people grossly over-estimate the size of a unit of alcohol.
Kaskutas & Graves asked women to pour a unit of alcohol.
Most poured too much, by up to a factor of three.
So, our virtuous woman, restricting herself to what she thinks is two units, could be having six units of alcohol.
In effect, she would be binge-drinking twice or more a week!
Another information resource, The Midwives Information and Resource Service states:
“pregnant women can be reassured that light infrequent drinking constitutes no risk to their baby”.
This is dangerous rubbish!
There is a hell of a difference between “no evidence of risk” and “no risk at all”.
Additional advice from the National Institute for Health and Clinical Excellence (NICE):
advises women to avoid alcohol in the first three months in particular,
because of the increased risk of miscarriage.
For the rest of the pregnancy the advice seems to be about moderation.
I think this is poor and that an average person reading the NICE advice might take it to mean that alcohol is Ok after 12 weeks.
It would have been better to give a simple message:
"Alcohol can cause severe damage to the baby while it is in the womb.
Don't drink alcohol if you are pregnant.
Don't drink alcohol if you are trying to become pregnant.
Don't drink alcohol if you could become pregnant because you are not using reliable contraception.
If you think you have could have a problem with not drinking alcohol at all, talk about it to your doctor before thinking about becoming pregnant".
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How to screen for alcohol problems in pregnancy.
The RCOG's Statement No 5 of 2006 "Alcohol consumption and the outcomes of pregnancy" includes the following:
"It is important for GPs, obstetricians and midwives:
to devise ways of identifying women
who may suffer from problem drinking
during or before any pregnancy
at a time when potentially beneficial interventions can be offered".
But it does not specify what methods might best be employed.
There are blood tests which could be used to screen for alcohol abuse:
Gamma glutamyl transpeptidase GGT and
Carbohydrate_deficient_transferrin CDT.
We are a bit schizophrenic about routine screening.
Most hospital still screen for syphilis without getting formal consent.
Yet we baulk at using blood tests to screen for alcohol abuse.
The RCOG "Statement No 5"
You will occasionally be alerted the problem from a raised MCV on a routine FBC.
Remember this one for the MCQs.
It could also turn up in an OSCE station with you asked for appropriate action on receipt of various results.
So, we mostly just use questionnaires.
There are stacks of these:
CAGE,
MAST etc.
The most commonly used in antenatal clinics is T-ACE, though some use CAGE.
For screening to be effective you need:
staff trained to understand the importance of screening,
a proven screening tool,
staff trained to use the screening tool effectively,
a protocol for the management of women who screen positive.
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You can quote the College advice for the exam.
But be prepared to criticise it in a short essay anwer.
In real life you should counsel abstinence until a safe lower limit has been proved, which is unlikely to happen.
Even then you would need to be sure that women knew how much alcohol they were taking.
Interventions in pregnancy have been shown to be effective.
The great difficulty is detecting the woman with an alcohol problem and getting her to accept treatment.
Individuals with alcohol addiction are notoriously incapable of facing up to their problem.
And will grossly under-report their consumption.
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