What is the recommended approach for managing alcohol withdrawal in pregnant women in Ontario?

Management of Alcohol Withdrawal in Pregnant Women in Ontario

Alcohol withdrawal in pregnant women should be treated with benzodiazepines, as the risks of untreated withdrawal syndrome to both mother and fetus outweigh the theoretical concerns about benzodiazepine use in pregnancy. 1

Primary Treatment Approach

Benzodiazepines are the recommended pharmacologic treatment for alcohol withdrawal syndrome in pregnancy. 1 The European Association for the Study of Liver explicitly states that withdrawal syndrome should be treated with benzodiazepines, recognizing that untreated alcohol withdrawal poses greater maternal and fetal risks than medication exposure. 1

Critical Context for Decision-Making

The decision to treat alcohol withdrawal aggressively in pregnancy is driven by several factors:

• Untreated alcohol withdrawal can be fatal to both mother and fetus, making intervention medically necessary despite pregnancy. 1
• Alcohol use during pregnancy causes preterm birth, small for gestational age infants, fetal alcohol spectrum disorder, and fetal alcohol syndrome—all causing permanent impairments. 1
• Delirium tremens carries up to 50% mortality without treatment. 2

Screening and Assessment Framework

All pregnant women should undergo universal screening for alcohol use using validated instruments. 3

• Use the TWEAK or T-ACE screening tools specifically designed for pregnant women to detect lower-level consumption. 3
• Assess quantity, frequency, heavy episodic drinking, and behavioral manifestations using the AUDIT questionnaire for those screening positive. 1
• Screen for alcohol use disorder using DSM-5 criteria. 1

Psychosocial Interventions as First-Line

Psychosocial treatment is the primary intervention for alcohol use disorder in pregnancy and should be initiated immediately upon identification. 1, 4

• Brief multicomponent interventions using the FRAMES framework (Feedback, Responsibility, Advice, Menu of options, Empathetic counseling, Self-efficacy) effectively reduce alcohol consumption and increase abstinence rates. 3
• The 5 A's framework (Assess, Advise, Agree, Assist, Arrange) provides a structured approach deliverable by any healthcare team member. 3
• These interventions require approximately 15 minutes initially with follow-up support. 3

Pharmacologic Management of Alcohol Use Disorder

When psychosocial interventions fail and continued alcohol use poses ongoing fetal risk, medication-assisted treatment may be considered:

Acceptable Options

Naltrexone or acamprosate may be used when psychosocial interventions have failed and continued alcohol exposure outweighs theoretical medication risks. 1, 4

• Limited human data for naltrexone and acamprosate did not show fetal abnormalities. 1, 4
• The decision must weigh the documented harms of continued alcohol exposure (fetal alcohol spectrum disorder, preterm birth, growth restriction) against limited safety data for these medications. 1, 4

Contraindicated Medications

Disulfiram is absolutely contraindicated in pregnancy due to association with fetal abnormalities. 1, 4

Baclofen should be used with extreme caution as it may accumulate and cause neonatal withdrawal syndrome. 1, 4

Clinical Pitfalls to Avoid

• Never withhold benzodiazepines for alcohol withdrawal treatment solely due to pregnancy status—untreated withdrawal poses greater risk. 1
• Never use disulfiram under any circumstances in pregnancy. 1, 4
• Do not recommend acute detoxification or attempting to wean alcohol before delivery for most women, as acute maternal withdrawal and relapse can be harmful or fatal to both mother and fetus. 1
• Avoid opioid agonist/antagonists (nalbuphine, butorphanol) as they can precipitate withdrawal if the patient has concurrent opioid use. 1

Priority Access and Disposition

Pregnant women should be given priority access to withdrawal management and treatment services. 5

• Intensive culture-, gender-, and family-appropriate interventions must be available and accessible for women with problematic drinking and alcohol dependence. 5
• Severe withdrawal requiring high-dose benzodiazepines, phenobarbital, or alternative medications necessitates intensive care unit admission with critical care consultation. 2

Counseling Considerations

All pregnant women must be advised to abstain completely from alcohol, as no safe threshold of consumption during pregnancy has been established. 1, 3

• Low-level alcohol consumption in early pregnancy is NOT an indication for pregnancy termination. 5
• Create a safe, non-judgmental environment for women to report alcohol consumption without fear of punitive consequences. 5