Prenatal Alcohol Screening: The Aberdeen Instrument

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Prenatal Alcohol Screening The Aberdeen
Instrument

• Martha J. Wunsch, MD FAAP
• Pediatrics and Addiction Medicine
• Edward Via Virginia College of Osteopathic
  Medicine

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Addressing Alcohol Use in Pregnancy

• Role of the Physician
• Women and Alcohol Use
• How to Ask
• How to Advise
• How to Assist

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Key Clinical Practices

• Ask
• All women of childbearing age about alcohol use
• All pregnant women about alcohol use
• Advise
• All women planning a pregnancy that no alcohol is
  the safest choice
• All pregnant women that no alcohol is the safest
  choice
• women who consumed alcohol during their pregnancy
  to contact local resources and services
• Assist
• assist women to stop drinking through
  information, counseling, care and referral to
  appropriate programs and services

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Provider Concerns

• Providers may
• Lack knowledge
• be uncomfortable asking about alcohol use
• - have concerns about patient response
• have personal issues about alcohol use
• lack time
• be unsure how to ask women
• be unaware of effective screening tools
• be unsure how to advise women
• be unaware of services for women who are having
  difficulty changing drinking behavior

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Opportunity

• Pregnancy is an opportunity for change
• Women who are pregnant are more receptive to
  intervention programs and treatment than women
  who are not currently pregnant

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Under Reporting

• Women may choose to under-report alcohol use
  because they
• Feel guilty about their alcohol use
• Fear being judged
• Fear loosing their baby or other children
• Lack knowledge about standard drink sizes

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Standard Drink?
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Common Drinking Patterns

• Abstainers do not consume alcohol
• Low-risk drinkers consume 1-2 drinks per day, no
  more than 9 per week
• High-risk drinkers consume more than 21 drinks
  per week
• Alcohol-dependant drinkers cannot stop drinking
  once they start
• Binge drinkers consume 5 or more drinks per
  occasion

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At Risk Drinking

• Many women may unintentionally drink while
  pregnant due to delayed pregnancy recognition
• Women who binge drink are at increased risk for
  unintended pregnancy

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At Risk Drinking

• There are no known benefits to alcohol use during
  pregnancy
• The level of harm is dose related
• Adverse effects to the fetus are related to the
  peak blood alcohol levels
• Damage to the fetus is most likely to occur with
  higher levels of alcohol use including
• Average of 2 or more drinks a day (heavy
  drinking)
• 5-6 drinks on some occasions (binge drinking)

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Safe Limits?

• No known safe limit for alcohol use in pregnancy
• FAS is most strongly associated with heavy or
  binge drinking
• Moderate levels of drinking may be associated
  with low birth weight, IUGR, miscarriage,
  stillbirth, developmental and neuro-behavioral
  problems, however, more research is needed in
  this area
• Health care providers should advise patients that
  the safest choice is not to consume alcohol
  during pregnancy

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When Screening

• A positive response is likely to be accurate,
  however a negative response may not be accurate
• Continue to ask about alcohol use on subsequent
  visits and watch for signs and symptoms of
  alcohol use
• Screening will assist in identifying higher risk
  drinking and can help you link patients to needed
  resources and services
• The goal is to reduce all forms of maternal
  alcohol use

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If Your Patient is not Planning a Pregnancy

• Ask determine risk of an unplanned pregnancy and
  drinking level
• Advise
• If you decide to get pregnant, it is safest to
  stop drinking.
• Your level of alcohol use may put you at risk
  for an unplanned pregnancy.
• Assist discuss reliable long-term birth control
  methods

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Birth Control

• Alcohol use can result in an unplanned or
  unwanted pregnancy
• Barriers to family planning include
• Drug or alcohol use
• Lack of access
• Lack of partner support

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If Your Patient is Planning a Pregnancy

• Ask drinking level
• Advise
• It is safest to stop drinking before you get
  pregnant.
• Alcohol can hurt your baby.
• Assist delay pregnancy until she stops drinking
  alcohol

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If your Patient is Pregnant

• Ask drinking status
• Advise
• It is safest to stop drinking as soon as
  possible.
• Refer to treatment or supportive counseling if
  indicated
• Assist reduce alcohol use as soon as possible

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When and Who to Ask?

• Ask everyone as alcohol use is widespread and
  many heavy users do not present with effects
• Ask early and often
• Key times to assess
• Initial visit
• Annual gynecological visit
• Preconception visit
• Prenatal Care (throughout)

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Office Environment

• Consider putting up posters on alcohol and
  pregnancy
• Supply patient handouts such as brochures
• Use a trigger to remind you to ask about alcohol
  use

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Effective Screening

• Emphasize that the questions are routine and that
  you ask all patients to improve your practice
• Avoid stating questions to provoke a quick no.
• You dont drink, do you?
• How much alcohol do you drink?
• When was your last drink?

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The Aberdeen Instrument

• Developed in 1994 and validated in a PHS hospital
• Designed to be self-administered and reviewed
  with a public health nurse
• Education was provided with the questionnaire
• Identified 75 of women who drank while pregnant

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The Aberdeen Instrument

• How many drinks does it take for you to first
  feel the effects of alcohol?
• When was your last drink?
• Do you ever feel that you should cut down on
  your drinking?
• Do any friends or family ask you to drink less?
• Some questions appear redundant at first, but
  they each approach drinking from a different way.
  

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During Screening

• Follow up the screening questions with probes
• Be non-judgmental
• Listen attentively to her concerns
• Refrain from negative comments or reactions
• Focus on your patient as well as her baby
• Be sensitive to broader issues and contexts such
  as poverty or abuse
• Make positive statements about the woman seeking
  prenatal care
• Make positive statements about progress during
  each visit

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Advise to Stop Drinking

• Recommend that patients stop drinking if they are
  planning a pregnancy or if they are pregnant
• Use a clear statement such as
• When planning a pregnancy, it is safest to stop
  drinking before you become pregnant.
• The safest choice is not to drink during
  pregnancy.
• Now that you know you are pregnant, it is safest
  to stop drinking.

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Advise About Risk

• Use positive statements to provide an accurate
  assessment of risks.
• Positive If you stop drinking you have a better
  chance of having a healthy baby.
• Negative Your drinking has already damaged your
  baby.

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Advise About Risk

• Positive Your concern for your baby will help
  you be a good mother
• Negative If you really loved your baby, you
  would not drink so much

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How to Assist

• Discuss alcohol use in a comfortable,
  non-threatening manner.
• Effective strategies are
• Non-judgmental
• Use motivational enhancement
• honest and open
• women-centered
• Build on strengths
• culturally sensitive
• supportive

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Questions?

• Martha J. Wunsch, MD FAAP
• Associate Professor
• Edward Via Virginia College of Osteopathic
  Medicine
• 2265 Kraft Drive, Blacksburg, VA 24060
• 540-231-4477
• Email mwunsch_at_vcom.vt.edu