National Drug Strategy
National Drug Strategy

Intergovernmental committee on Drugs working party on Fetal Alcohol Spectrum Disorders

Monograph

Fetal Alcohol Spectrum Disorders in Australia: An Update

June 2012

3.3 Supportive therapy

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The following section provides a summary of the information contained in the Background Papers To the National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn (NSW Department of Health 2006).

Framework of care

Alcohol treatment is associated with improved maternal and neonatal outcomes, with more intensive treatment episodes associated with the best outcomes. Education, monitoring and screening throughout pregnancy is effective for women who are low-risk drinkers (Redding and Selleck 1993) . Education and abstinence is suggested for those at moderate risk, and these programs should also include risk management, contracts and monitoring. Alcohol dependent women who choose to withdraw should be admitted to an inpatient unit and receive close medical supervision, including monitoring of both the mother and the fetus (Mitchell 1993).

If women are not dependent but wish to stop drinking, other settings are also appropriate and may include:

Table 3.1: Pharmacotherapies for alcohol problems among pregnant women



Drug Used forRisksAustralian TGA pregnancy classification
BenzodiazepinesManagement of alcohol withdrawal Early studies note minor congenital malformations, such as cleft palate after first trimester exposure. Later studies did not find this result. Pooled data indicated the risk is very small, especially with short-term exposure. Benzodiazepines in the third trimester or close to delivery may cause floppy infant syndrome.Category C
CarbamazepineAnticonvulsant medication used in alcohol
patients who have multiple episodes of
withdrawal
Contraindicated in pregnant women. A twofold increase in major congenital abnormalities has been found in epileptic women who took the drug during the first trimester of pregnancyCategory D
ValproateAlcohol withdrawalProduces neural tube defects and is hence precluded from use in pregnancy.Category D
ThiaminePrevention of Wernicke’s encephalopathy
and Korsakoff’s syndrome in the mother.
RecommendedUnlisted: see product
Information
Folic acidPrevention of neural tube defectsRecommendedCategory A
DisulfiramUsed in the abstinence phase of alcohol
treatment and inhibits aldehyde
dehydrogenase, leading to a build up of
acetaldehyde. This causes an unpleasant
reaction when alcohol is consumed, with
facial flushing, tachycardia, hypotension,
nausea, vomiting, and general malaise.
Evidence on adverse effects during pregnancy are scant and it is therefore not recommended for use.Category B2
NaltrexoneOpiate agonist that reduces the positive
reinforcement of alcohol.
Contradindicated in pregnancy and lactation. An Australian case study of 18 women reported naltrexone did not increase fetal abnormalities (Hulse et al. 2004).Category B3
AcamprosateReduces the hyperexcitable state that
results from chronic alcohol use.
No information on studies in pregnant women was found.Category B2
ClonidineAlcohol withdrawal.No controlled data from human pregnancy studies.Category B3

Category A - Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.

Category B2 - Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage.

Category B3- Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have shown evidence of an increased occurrence of fetal damage, the significance of which is considered uncertain in humans.

Category C - Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Accompanying texts should be consulted for further details.

Category D- Drugs which have caused, are suspected to have caused or may be expected to cause, an increased incidence of human fetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects. Accompanying texts should be consulted for further details. www.tg.org.au/etg_demo/tgc/plg/breastfeeding_c.htm (This website link was valid at the time of submission)

Following delivery, discharge planning should include relapse prevention and referral to community services, including a general practitioner. Parenting groups are also recommended (Greenfield and Sugarman 2001). Following birth, treatment should focus on keeping the
baby with the mother and promoting attachment between them. Interventions that aim to increase the mother’s self esteem and/or self-efficacy are suggested; however, at the present most treatment settings do not make provision for babies or for other children to remain in the
care of their mothers (Bowie 2005).

Overall, women should be engaged in treatment as early as possible and will be best conducted in a supportive, culturally sensitive and non-judgemental environment. This will require a full health and psychosocial assessment (Mitchell 1993). Factors associated with early attrition from treatment programs include high levels of drug craving and withdrawal, more prior drug treatment episodes, fewer medical and drug problems and more family and social and psychiatric problems (Kissin et al. 2004).

There is no clear empirical evidence as to which modality is best suited to substance-using women (including inpatients and outpatients). A recent review of integrated treatment programs (programs that combine substance use treatment and pregnancy, parenting or child services) suggests that integrated programs result in significant reductions in substance use and are more effective than no treatment in reducing maternal substance misuse (Milligan et al. 2011). A number of components of successful programs have been identified including:
positive parent role models and parent training; self-help groups; outreach; case management; life skills management; family support services; lengthy follow-up; and referrals and support across a range of domains including medical, pharmalogical, transportation, mental health, educational, vocational, legal and respite care (Lester et al. 2004).

There is a need to conduct further research to identify effective programs for pregnant women who use alcohol (Lester et al. 2004). In particular, there is little evidence on the effectiveness of the psychosocial treatment of pregnant women with alcohol dependence. A systematic review of psychosocial interventions for pregnant women enrolled in alcohol treatment programs found no randomised or quasi-randomised studies comparing any psychosocial intervention with other intervention for treating alcohol dependence in pregnancy (Lui et al. 2009). The authors of the review conclude that controlled trials need to be performed on this population of women to determine the most effective therapy for pregnant women seeking treatment for alcohol dependence. There have been trials designed to reduce alcohol use in pregnant women but these have not specifically focussed on pregnant women currently in alcohol treatment programs.
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