Clinical Review

 

The authors report no financial relationships relevant to this article.

If there have been overriding themes in obstetrics over the past year, they have been “more,” “sooner,” “faster,” “safer.” Advances in our field have thrilled our scientific curiosity and increased our ability to alleviate suffering—but at what cost? And who will pay that cost?

In this Update, we focus on recent advances in prenatal diagnosis and fetal therapy, as well as the ever-encroaching economic barriers that may limit our ability to get what we want. In particular, we will discuss:

 

• two technologies in prenatal genetics: noninvasive aneuploidy testing using cell-free DNA and prenatal microarray analysis
• open fetal surgery to reduce mortality and improve the function and quality of life for fetuses with open neural tube defects
• the value and probable impact of bundled payments—that is, one payment for multiple services grouped into one “episode.”

Two noninvasive approaches to prenatal diagnosis offer promise—but practicality and cost are uncertain

Ashoor G, Syngelaki RM, Wagner M, Birdir C, Nicolaides KH. Chromosome-selective sequencing of maternal plasma cell-free DNA for first-trimester detection of trisomy 21 and trisomy 18. Am J Obstet Gynecol. 2012;206(4):322.e1–e5.

Reddy UM, Page GP, Saade GR, et al. Karyotype versus microarray testing for genetic abnormalities after stillbirth. N Engl J Med. 2012;367(23):2185–2193.

Talkowski ME, Ordulu Z, Pillalamarri V, et al. Clinical diagnosis by whole-genome sequencing of a prenatal sample. N Engl J Med. 2012;367(23):2226–2232.

Wapner RJ, Martin CL, Levy B, et al. Chromosomal microarray versus karyotyping for prenatal diagnosis. N Engl J Med. 2012;367(23):2175–2184.

Genetic screening and testing are a standard part of prenatal care in most developed countries. We have come a long way since a maternal age of 35 years was the only variable separating patients into low- and high-risk categories. This year, two technologies have emerged that may change forever the way we approach prenatal genetics:

 

• noninvasive aneuploidy testing using cell-free DNA
• prenatal microarray analysis.^1–4

One argument for using more accurate genetic screening methods: They limit the number of invasive tests that are needed. Chorionic villus sampling (CVS) and amniocentesis, even when performed by the most experienced of operators, pose a small but real risk of fetal injury and pregnancy loss.

Noninvasive aneuploidy diagnosis is now a reality in high-risk population screening

The holy grail of aneuploidy diagnosis would be a noninvasive way to sample fetal cells. Although we have known for decades that fetal cells enter the maternal circulation, it has been impractical to use them for aneuploidy testing because of their scarcity and longevity. In the 1990s, however, cell-free fetal DNA (cffDNA), a compound of DNA fragments of uncertain origin, was identified in maternal plasma. CffDNA is more plentiful than fetal cells. It also disappears within hours of delivery, demonstrating that it is specific to the current pregnancy.

CffDNA is already used in fetal Rh typing and gender determination in disorders such as congenital adrenal hyperplasia. Several studies in high-risk populations have demonstrated high sensitivity and specificity for the detection of Trisomies 21, 18, and 13. Several commercial tests are now available, although neither their accuracy nor their cost has been determined for use in low-risk population screening, compared with traditional testing.

Microarray analysis, paired with karyotyping, can elucidate ultrasound-identified fetal anomalies

Cytogenetic microarray analysis is also being explored in the prenatal period. Microarray analysis is currently used as a first-line test for infants and children who demonstrate developmental delay, autism spectrum disorders, dysmorphic features, and congenital anomalies. As many as 15% of patients with an otherwise normal karyotype will have a clinically significant copy number variant (CNV) on microarray. This finding has led to the use of microarray analysis in conjunction with karyotyping for fetuses with ultrasound-identified anomalies. Both targeted arrays (for syndromes associated with ultrasound anomalies) and whole-genome arrays are available.

Recent data from a study from the National Institute of Child Health and Human Development (NICHD) reveal that the prenatal detection rates for aneuploidy and unbalanced translocations are comparable between microarray analysis and karyotyping. Microarray analysis did not, however, detect triploidies or balanced translocations. As many as 6% of patients with a normal karyotype and structural anomalies and 1.7% of patients with advanced maternal age or positive screening tests had either a known or potentially clinically relevant CNV. This large study concluded that microarray analysis not only provides equal detection of aneuploidy but also more information in the form of CNVs, compared with karyotyping alone.

 

Microarray analysis also has been used in the study of pregnancy loss and stillbirth because it does not require viable or intact tissue as a source of DNA—an advantage, compared with traditional karyotyping. A recent study from the Stillbirth Collaborative Research Network demonstrated that genetic results in cases involving stillbirth were obtained more frequently via microarray analysis (87.4%) than by karyotype (70.5%). In addition, more genetic abnormalities (aneuploidy, pathogenic CNVs, and CNVs of unknown clinical significance) were detected by microarray analysis. Investigators concluded that microarray analysis may be especially useful in cases involving stillbirth (when a karyotype cannot be obtained) and structural abnormalities.

 

Should microarray analysis replace routine prenatal genetic testing?

A major dilemma associated with this technology is the significant amount of time that may be needed to counsel patients when the results are of unclear clinical significance.⁵ If the fetus has an anomaly, and a related CNV is identified, then counseling of the parents is fairly straightforward. However, if the fetus has an anomaly and a CNV that has not yet been defined, what should the parents be told? Some argue that this information should not be shared with the parents, whereas others recommend full disclosure of all results—even if we do not yet know what to make of them.

Another issue with microarray analysis is its inability to detect balanced translocations, triploidies, and low-level mosaicism, which require either a karyotype or whole-genome sequencing. Microarray analysis is also more expensive than karyotyping, although this may change in the future.

>Fetal therapy involves a complex equation of potential benefits and risks

Adzick NS, Thom EA, Spong CY, et al; MOMS Investigators. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med. 2011;364(11):993–1104.

Fetal therapy is broadly defined as any intervention administered to or via the mother with a primary indication to improve perinatal or long-term outcomes for the fetus or newborn. The concept of intervening to prevent the death of a fetus by correcting an anatomic anomaly or halting a disease process in utero is not new. Liley performed the first intrauterine fetal transfusion for Rh alloimmunization in the 1960s. Today, we perform fetal interventions routinely to reduce mortality by giving medical therapy to the mother, such as antenatal corticosteroids to enhance fetal lung maturity or anti-arrhythmics for supraventricular tachycardia. More invasive procedures have proved to be lifesaving (placental laser coagulation for twin-twin transfusion syndrome), ameliorating in the short term (shunting for lower urinary tract obstruction to relieve oligohydramnios), or ultimately not helpful (decompression of hydrocephalus).

Most recently, open fetal surgery has taken center stage as an intervention focused not only on reducing mortality but on improving function and quality of life for fetuses with open neural tube defects (ONTDs). This anomaly was targeted for fetal intervention because, although ONTDs are not generally considered lethal, a significant number of patients die before the age of 5, the majority of patients require shunts that leave them vulnerable to complications, and ONTDs generally impose lifelong intellectual and physical limitations. Repair during fetal life was proposed to prevent damage to the spinal cord and reverse hindbrain herniation, with the goal of improving long-term neurologic function.

The Management of Myelomeningocele Study (MOMS) is a prospective, multicenter trial that randomly assigned fetuses with isolated ONTDs to open fetal repair of myelomeningocele via hysterotomy or to postnatal repair of the defect. Forty percent of infants who underwent fetal repair required placement of a shunt, compared with 82% of those who had postnatal repair (relative risk, 0.48; 97.7% CI, 0.36 to 0.64; P<.001). Infants in the fetal-repair group also had significantly improved composite scores for mental development and motor function at 30 months (P = .007), as well as improvement in secondary outcomes such as hindbrain herniation and independent walking at 30 months.

As exciting as these results are, open fetal surgery still has significant limitations. The few centers that perform the most complex surgeries often have strict exclusion criteria, including maternal body mass index (BMI) greater than 35 kg/m² and other medical comorbidities. The surgery also poses real risks for both mother and fetus. In the MOMS trial, the risk of preterm labor increased in the fetal-repair group, compared with postnatal repair (38% vs 14%), as did the risk of premature rupture of membranes (46% vs 8%). The fetal-repair group delivered more than 3 weeks earlier than the postnatal repair group (34 vs 37 weeks). Twenty-five percent of the fetal-repair group had thinning of the uterine scar, with uterine dehiscence seen in 10%. When myelomeningocele is repaired during fetal life, mothers require two hysterotomies during pregnancy and face an increased risk of uterine rupture and preterm delivery in subsequent pregnancies. The use of tocolytics exposes these mothers to an increased risk of pulmonary edema (6% in the fetal-repair group vs 0% for postnatal repair).

 

Other issues that should be addressed:

 

• the need for rigorous study of open fetal surgery for other fetal anomalies
• prognostic factors for success and for complications
• long-term outcomes in neurologic development of children and fertility of mothers
• a comparison of costs between fetal and postnatal treatment.

 

Bundled payments may help us deliver higher-quality, more efficient, and less costly care

Centers for Medicare and Medicaid Services, US Department of Health and Human Services. Fact Sheet: Bundled Payments for Care Improvement Initiative. Washington, DC: DHS; 2011. http://innovations.cms.gov/Files/fact-sheet/Bundled-Payment-Fact-Sheet.pdf. Accessed December 6, 2012.

There is little question that health care in the United States needs reform. The culture of “more is better” is not sustainable economically—nor does our health as a whole reflect the amount of money that we spend on health care, compared with other countries. Although the future is not yet clear, one proposed mechanism for reform is the institution of bundled payments—the grouping of multiple services into one “episode” for payment purposes. An episode might include inpatient hospitalization for pneumonia, for example, or the grouping of surgery with post-discharge care. In obstetrics, all pregnancy care could be grouped into one episode. The concept behind bundled payments is to provide incentives to institutions and providers to delivery higher-quality, more efficient, and less costly care.

If bundled payments become the reality for obstetric care in the future, how will that affect the way we care for our patients? Instead of blindly ordering all available tests, we need to consider thoroughly whether the patient truly needs a test to improve pregnancy outcomes. We also need to consider whether other measures might be avoided safely to keep costs within the bundle. A few examples:

 

• Is a screening fetal echocardiogram really necessary in a diabetic woman if the ultrasound anatomy scan is sufficient to rule out any cardiac anomaly that might require intervention in the delivery room?
• How will we integrate the expense of cell-free fetal DNA aneuploidy testing and microarray analysis, not to mention the extended counseling sessions that will be necessary to explain findings of uncertain clinical significance, into the bundle? Will “low-risk” patients need to pay out of pocket?

 

 

• Will a second ultrasound scan to visualize the fetal spine in a patient with a normal alpha-fetoprotein level be included in the bundle or paid for by the patient?

These issues may seem trivial, but we can no longer afford to order every test available. We will need to spend more time examining and counseling our patients so that they feel they are still getting the best care possible.

We want to hear from you! Tell us what you think.

 

The authors report no financial relationships relevant to this article.

If there have been overriding themes in obstetrics over the past year, they have been “more,” “sooner,” “faster,” “safer.” Advances in our field have thrilled our scientific curiosity and increased our ability to alleviate suffering—but at what cost? And who will pay that cost?

In this Update, we focus on recent advances in prenatal diagnosis and fetal therapy, as well as the ever-encroaching economic barriers that may limit our ability to get what we want. In particular, we will discuss:

 

• two technologies in prenatal genetics: noninvasive aneuploidy testing using cell-free DNA and prenatal microarray analysis
• open fetal surgery to reduce mortality and improve the function and quality of life for fetuses with open neural tube defects
• the value and probable impact of bundled payments—that is, one payment for multiple services grouped into one “episode.”

Two noninvasive approaches to prenatal diagnosis offer promise—but practicality and cost are uncertain

Ashoor G, Syngelaki RM, Wagner M, Birdir C, Nicolaides KH. Chromosome-selective sequencing of maternal plasma cell-free DNA for first-trimester detection of trisomy 21 and trisomy 18. Am J Obstet Gynecol. 2012;206(4):322.e1–e5.

Reddy UM, Page GP, Saade GR, et al. Karyotype versus microarray testing for genetic abnormalities after stillbirth. N Engl J Med. 2012;367(23):2185–2193.

Talkowski ME, Ordulu Z, Pillalamarri V, et al. Clinical diagnosis by whole-genome sequencing of a prenatal sample. N Engl J Med. 2012;367(23):2226–2232.

Wapner RJ, Martin CL, Levy B, et al. Chromosomal microarray versus karyotyping for prenatal diagnosis. N Engl J Med. 2012;367(23):2175–2184.

Genetic screening and testing are a standard part of prenatal care in most developed countries. We have come a long way since a maternal age of 35 years was the only variable separating patients into low- and high-risk categories. This year, two technologies have emerged that may change forever the way we approach prenatal genetics:

 

• noninvasive aneuploidy testing using cell-free DNA
• prenatal microarray analysis.^1–4

One argument for using more accurate genetic screening methods: They limit the number of invasive tests that are needed. Chorionic villus sampling (CVS) and amniocentesis, even when performed by the most experienced of operators, pose a small but real risk of fetal injury and pregnancy loss.

Noninvasive aneuploidy diagnosis is now a reality in high-risk population screening

The holy grail of aneuploidy diagnosis would be a noninvasive way to sample fetal cells. Although we have known for decades that fetal cells enter the maternal circulation, it has been impractical to use them for aneuploidy testing because of their scarcity and longevity. In the 1990s, however, cell-free fetal DNA (cffDNA), a compound of DNA fragments of uncertain origin, was identified in maternal plasma. CffDNA is more plentiful than fetal cells. It also disappears within hours of delivery, demonstrating that it is specific to the current pregnancy.

CffDNA is already used in fetal Rh typing and gender determination in disorders such as congenital adrenal hyperplasia. Several studies in high-risk populations have demonstrated high sensitivity and specificity for the detection of Trisomies 21, 18, and 13. Several commercial tests are now available, although neither their accuracy nor their cost has been determined for use in low-risk population screening, compared with traditional testing.

Microarray analysis, paired with karyotyping, can elucidate ultrasound-identified fetal anomalies

Cytogenetic microarray analysis is also being explored in the prenatal period. Microarray analysis is currently used as a first-line test for infants and children who demonstrate developmental delay, autism spectrum disorders, dysmorphic features, and congenital anomalies. As many as 15% of patients with an otherwise normal karyotype will have a clinically significant copy number variant (CNV) on microarray. This finding has led to the use of microarray analysis in conjunction with karyotyping for fetuses with ultrasound-identified anomalies. Both targeted arrays (for syndromes associated with ultrasound anomalies) and whole-genome arrays are available.

Recent data from a study from the National Institute of Child Health and Human Development (NICHD) reveal that the prenatal detection rates for aneuploidy and unbalanced translocations are comparable between microarray analysis and karyotyping. Microarray analysis did not, however, detect triploidies or balanced translocations. As many as 6% of patients with a normal karyotype and structural anomalies and 1.7% of patients with advanced maternal age or positive screening tests had either a known or potentially clinically relevant CNV. This large study concluded that microarray analysis not only provides equal detection of aneuploidy but also more information in the form of CNVs, compared with karyotyping alone.

 

Microarray analysis also has been used in the study of pregnancy loss and stillbirth because it does not require viable or intact tissue as a source of DNA—an advantage, compared with traditional karyotyping. A recent study from the Stillbirth Collaborative Research Network demonstrated that genetic results in cases involving stillbirth were obtained more frequently via microarray analysis (87.4%) than by karyotype (70.5%). In addition, more genetic abnormalities (aneuploidy, pathogenic CNVs, and CNVs of unknown clinical significance) were detected by microarray analysis. Investigators concluded that microarray analysis may be especially useful in cases involving stillbirth (when a karyotype cannot be obtained) and structural abnormalities.

 

Should microarray analysis replace routine prenatal genetic testing?

A major dilemma associated with this technology is the significant amount of time that may be needed to counsel patients when the results are of unclear clinical significance.⁵ If the fetus has an anomaly, and a related CNV is identified, then counseling of the parents is fairly straightforward. However, if the fetus has an anomaly and a CNV that has not yet been defined, what should the parents be told? Some argue that this information should not be shared with the parents, whereas others recommend full disclosure of all results—even if we do not yet know what to make of them.

Another issue with microarray analysis is its inability to detect balanced translocations, triploidies, and low-level mosaicism, which require either a karyotype or whole-genome sequencing. Microarray analysis is also more expensive than karyotyping, although this may change in the future.

>Fetal therapy involves a complex equation of potential benefits and risks

Adzick NS, Thom EA, Spong CY, et al; MOMS Investigators. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med. 2011;364(11):993–1104.

Fetal therapy is broadly defined as any intervention administered to or via the mother with a primary indication to improve perinatal or long-term outcomes for the fetus or newborn. The concept of intervening to prevent the death of a fetus by correcting an anatomic anomaly or halting a disease process in utero is not new. Liley performed the first intrauterine fetal transfusion for Rh alloimmunization in the 1960s. Today, we perform fetal interventions routinely to reduce mortality by giving medical therapy to the mother, such as antenatal corticosteroids to enhance fetal lung maturity or anti-arrhythmics for supraventricular tachycardia. More invasive procedures have proved to be lifesaving (placental laser coagulation for twin-twin transfusion syndrome), ameliorating in the short term (shunting for lower urinary tract obstruction to relieve oligohydramnios), or ultimately not helpful (decompression of hydrocephalus).

Most recently, open fetal surgery has taken center stage as an intervention focused not only on reducing mortality but on improving function and quality of life for fetuses with open neural tube defects (ONTDs). This anomaly was targeted for fetal intervention because, although ONTDs are not generally considered lethal, a significant number of patients die before the age of 5, the majority of patients require shunts that leave them vulnerable to complications, and ONTDs generally impose lifelong intellectual and physical limitations. Repair during fetal life was proposed to prevent damage to the spinal cord and reverse hindbrain herniation, with the goal of improving long-term neurologic function.

The Management of Myelomeningocele Study (MOMS) is a prospective, multicenter trial that randomly assigned fetuses with isolated ONTDs to open fetal repair of myelomeningocele via hysterotomy or to postnatal repair of the defect. Forty percent of infants who underwent fetal repair required placement of a shunt, compared with 82% of those who had postnatal repair (relative risk, 0.48; 97.7% CI, 0.36 to 0.64; P<.001). Infants in the fetal-repair group also had significantly improved composite scores for mental development and motor function at 30 months (P = .007), as well as improvement in secondary outcomes such as hindbrain herniation and independent walking at 30 months.

As exciting as these results are, open fetal surgery still has significant limitations. The few centers that perform the most complex surgeries often have strict exclusion criteria, including maternal body mass index (BMI) greater than 35 kg/m² and other medical comorbidities. The surgery also poses real risks for both mother and fetus. In the MOMS trial, the risk of preterm labor increased in the fetal-repair group, compared with postnatal repair (38% vs 14%), as did the risk of premature rupture of membranes (46% vs 8%). The fetal-repair group delivered more than 3 weeks earlier than the postnatal repair group (34 vs 37 weeks). Twenty-five percent of the fetal-repair group had thinning of the uterine scar, with uterine dehiscence seen in 10%. When myelomeningocele is repaired during fetal life, mothers require two hysterotomies during pregnancy and face an increased risk of uterine rupture and preterm delivery in subsequent pregnancies. The use of tocolytics exposes these mothers to an increased risk of pulmonary edema (6% in the fetal-repair group vs 0% for postnatal repair).

 

Other issues that should be addressed:

 

• the need for rigorous study of open fetal surgery for other fetal anomalies
• prognostic factors for success and for complications
• long-term outcomes in neurologic development of children and fertility of mothers
• a comparison of costs between fetal and postnatal treatment.

 

Bundled payments may help us deliver higher-quality, more efficient, and less costly care

Centers for Medicare and Medicaid Services, US Department of Health and Human Services. Fact Sheet: Bundled Payments for Care Improvement Initiative. Washington, DC: DHS; 2011. http://innovations.cms.gov/Files/fact-sheet/Bundled-Payment-Fact-Sheet.pdf. Accessed December 6, 2012.

There is little question that health care in the United States needs reform. The culture of “more is better” is not sustainable economically—nor does our health as a whole reflect the amount of money that we spend on health care, compared with other countries. Although the future is not yet clear, one proposed mechanism for reform is the institution of bundled payments—the grouping of multiple services into one “episode” for payment purposes. An episode might include inpatient hospitalization for pneumonia, for example, or the grouping of surgery with post-discharge care. In obstetrics, all pregnancy care could be grouped into one episode. The concept behind bundled payments is to provide incentives to institutions and providers to delivery higher-quality, more efficient, and less costly care.

If bundled payments become the reality for obstetric care in the future, how will that affect the way we care for our patients? Instead of blindly ordering all available tests, we need to consider thoroughly whether the patient truly needs a test to improve pregnancy outcomes. We also need to consider whether other measures might be avoided safely to keep costs within the bundle. A few examples:

 

• Is a screening fetal echocardiogram really necessary in a diabetic woman if the ultrasound anatomy scan is sufficient to rule out any cardiac anomaly that might require intervention in the delivery room?
• How will we integrate the expense of cell-free fetal DNA aneuploidy testing and microarray analysis, not to mention the extended counseling sessions that will be necessary to explain findings of uncertain clinical significance, into the bundle? Will “low-risk” patients need to pay out of pocket?

 

 

• Will a second ultrasound scan to visualize the fetal spine in a patient with a normal alpha-fetoprotein level be included in the bundle or paid for by the patient?

These issues may seem trivial, but we can no longer afford to order every test available. We will need to spend more time examining and counseling our patients so that they feel they are still getting the best care possible.

We want to hear from you! Tell us what you think.

 

The authors report no financial relationships relevant to this article.

If there have been overriding themes in obstetrics over the past year, they have been “more,” “sooner,” “faster,” “safer.” Advances in our field have thrilled our scientific curiosity and increased our ability to alleviate suffering—but at what cost? And who will pay that cost?

In this Update, we focus on recent advances in prenatal diagnosis and fetal therapy, as well as the ever-encroaching economic barriers that may limit our ability to get what we want. In particular, we will discuss:

 

• two technologies in prenatal genetics: noninvasive aneuploidy testing using cell-free DNA and prenatal microarray analysis
• open fetal surgery to reduce mortality and improve the function and quality of life for fetuses with open neural tube defects
• the value and probable impact of bundled payments—that is, one payment for multiple services grouped into one “episode.”

Two noninvasive approaches to prenatal diagnosis offer promise—but practicality and cost are uncertain

Ashoor G, Syngelaki RM, Wagner M, Birdir C, Nicolaides KH. Chromosome-selective sequencing of maternal plasma cell-free DNA for first-trimester detection of trisomy 21 and trisomy 18. Am J Obstet Gynecol. 2012;206(4):322.e1–e5.

Reddy UM, Page GP, Saade GR, et al. Karyotype versus microarray testing for genetic abnormalities after stillbirth. N Engl J Med. 2012;367(23):2185–2193.

Talkowski ME, Ordulu Z, Pillalamarri V, et al. Clinical diagnosis by whole-genome sequencing of a prenatal sample. N Engl J Med. 2012;367(23):2226–2232.

Wapner RJ, Martin CL, Levy B, et al. Chromosomal microarray versus karyotyping for prenatal diagnosis. N Engl J Med. 2012;367(23):2175–2184.

Genetic screening and testing are a standard part of prenatal care in most developed countries. We have come a long way since a maternal age of 35 years was the only variable separating patients into low- and high-risk categories. This year, two technologies have emerged that may change forever the way we approach prenatal genetics:

 

• noninvasive aneuploidy testing using cell-free DNA
• prenatal microarray analysis.^1–4

One argument for using more accurate genetic screening methods: They limit the number of invasive tests that are needed. Chorionic villus sampling (CVS) and amniocentesis, even when performed by the most experienced of operators, pose a small but real risk of fetal injury and pregnancy loss.

Noninvasive aneuploidy diagnosis is now a reality in high-risk population screening

The holy grail of aneuploidy diagnosis would be a noninvasive way to sample fetal cells. Although we have known for decades that fetal cells enter the maternal circulation, it has been impractical to use them for aneuploidy testing because of their scarcity and longevity. In the 1990s, however, cell-free fetal DNA (cffDNA), a compound of DNA fragments of uncertain origin, was identified in maternal plasma. CffDNA is more plentiful than fetal cells. It also disappears within hours of delivery, demonstrating that it is specific to the current pregnancy.

CffDNA is already used in fetal Rh typing and gender determination in disorders such as congenital adrenal hyperplasia. Several studies in high-risk populations have demonstrated high sensitivity and specificity for the detection of Trisomies 21, 18, and 13. Several commercial tests are now available, although neither their accuracy nor their cost has been determined for use in low-risk population screening, compared with traditional testing.

Microarray analysis, paired with karyotyping, can elucidate ultrasound-identified fetal anomalies

Cytogenetic microarray analysis is also being explored in the prenatal period. Microarray analysis is currently used as a first-line test for infants and children who demonstrate developmental delay, autism spectrum disorders, dysmorphic features, and congenital anomalies. As many as 15% of patients with an otherwise normal karyotype will have a clinically significant copy number variant (CNV) on microarray. This finding has led to the use of microarray analysis in conjunction with karyotyping for fetuses with ultrasound-identified anomalies. Both targeted arrays (for syndromes associated with ultrasound anomalies) and whole-genome arrays are available.

Recent data from a study from the National Institute of Child Health and Human Development (NICHD) reveal that the prenatal detection rates for aneuploidy and unbalanced translocations are comparable between microarray analysis and karyotyping. Microarray analysis did not, however, detect triploidies or balanced translocations. As many as 6% of patients with a normal karyotype and structural anomalies and 1.7% of patients with advanced maternal age or positive screening tests had either a known or potentially clinically relevant CNV. This large study concluded that microarray analysis not only provides equal detection of aneuploidy but also more information in the form of CNVs, compared with karyotyping alone.

 

Microarray analysis also has been used in the study of pregnancy loss and stillbirth because it does not require viable or intact tissue as a source of DNA—an advantage, compared with traditional karyotyping. A recent study from the Stillbirth Collaborative Research Network demonstrated that genetic results in cases involving stillbirth were obtained more frequently via microarray analysis (87.4%) than by karyotype (70.5%). In addition, more genetic abnormalities (aneuploidy, pathogenic CNVs, and CNVs of unknown clinical significance) were detected by microarray analysis. Investigators concluded that microarray analysis may be especially useful in cases involving stillbirth (when a karyotype cannot be obtained) and structural abnormalities.

 

Should microarray analysis replace routine prenatal genetic testing?

A major dilemma associated with this technology is the significant amount of time that may be needed to counsel patients when the results are of unclear clinical significance.⁵ If the fetus has an anomaly, and a related CNV is identified, then counseling of the parents is fairly straightforward. However, if the fetus has an anomaly and a CNV that has not yet been defined, what should the parents be told? Some argue that this information should not be shared with the parents, whereas others recommend full disclosure of all results—even if we do not yet know what to make of them.

Another issue with microarray analysis is its inability to detect balanced translocations, triploidies, and low-level mosaicism, which require either a karyotype or whole-genome sequencing. Microarray analysis is also more expensive than karyotyping, although this may change in the future.

>Fetal therapy involves a complex equation of potential benefits and risks

Adzick NS, Thom EA, Spong CY, et al; MOMS Investigators. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med. 2011;364(11):993–1104.

Fetal therapy is broadly defined as any intervention administered to or via the mother with a primary indication to improve perinatal or long-term outcomes for the fetus or newborn. The concept of intervening to prevent the death of a fetus by correcting an anatomic anomaly or halting a disease process in utero is not new. Liley performed the first intrauterine fetal transfusion for Rh alloimmunization in the 1960s. Today, we perform fetal interventions routinely to reduce mortality by giving medical therapy to the mother, such as antenatal corticosteroids to enhance fetal lung maturity or anti-arrhythmics for supraventricular tachycardia. More invasive procedures have proved to be lifesaving (placental laser coagulation for twin-twin transfusion syndrome), ameliorating in the short term (shunting for lower urinary tract obstruction to relieve oligohydramnios), or ultimately not helpful (decompression of hydrocephalus).

Most recently, open fetal surgery has taken center stage as an intervention focused not only on reducing mortality but on improving function and quality of life for fetuses with open neural tube defects (ONTDs). This anomaly was targeted for fetal intervention because, although ONTDs are not generally considered lethal, a significant number of patients die before the age of 5, the majority of patients require shunts that leave them vulnerable to complications, and ONTDs generally impose lifelong intellectual and physical limitations. Repair during fetal life was proposed to prevent damage to the spinal cord and reverse hindbrain herniation, with the goal of improving long-term neurologic function.

The Management of Myelomeningocele Study (MOMS) is a prospective, multicenter trial that randomly assigned fetuses with isolated ONTDs to open fetal repair of myelomeningocele via hysterotomy or to postnatal repair of the defect. Forty percent of infants who underwent fetal repair required placement of a shunt, compared with 82% of those who had postnatal repair (relative risk, 0.48; 97.7% CI, 0.36 to 0.64; P<.001). Infants in the fetal-repair group also had significantly improved composite scores for mental development and motor function at 30 months (P = .007), as well as improvement in secondary outcomes such as hindbrain herniation and independent walking at 30 months.

As exciting as these results are, open fetal surgery still has significant limitations. The few centers that perform the most complex surgeries often have strict exclusion criteria, including maternal body mass index (BMI) greater than 35 kg/m² and other medical comorbidities. The surgery also poses real risks for both mother and fetus. In the MOMS trial, the risk of preterm labor increased in the fetal-repair group, compared with postnatal repair (38% vs 14%), as did the risk of premature rupture of membranes (46% vs 8%). The fetal-repair group delivered more than 3 weeks earlier than the postnatal repair group (34 vs 37 weeks). Twenty-five percent of the fetal-repair group had thinning of the uterine scar, with uterine dehiscence seen in 10%. When myelomeningocele is repaired during fetal life, mothers require two hysterotomies during pregnancy and face an increased risk of uterine rupture and preterm delivery in subsequent pregnancies. The use of tocolytics exposes these mothers to an increased risk of pulmonary edema (6% in the fetal-repair group vs 0% for postnatal repair).

 

Other issues that should be addressed:

 

• the need for rigorous study of open fetal surgery for other fetal anomalies
• prognostic factors for success and for complications
• long-term outcomes in neurologic development of children and fertility of mothers
• a comparison of costs between fetal and postnatal treatment.

 

Bundled payments may help us deliver higher-quality, more efficient, and less costly care

Centers for Medicare and Medicaid Services, US Department of Health and Human Services. Fact Sheet: Bundled Payments for Care Improvement Initiative. Washington, DC: DHS; 2011. http://innovations.cms.gov/Files/fact-sheet/Bundled-Payment-Fact-Sheet.pdf. Accessed December 6, 2012.

There is little question that health care in the United States needs reform. The culture of “more is better” is not sustainable economically—nor does our health as a whole reflect the amount of money that we spend on health care, compared with other countries. Although the future is not yet clear, one proposed mechanism for reform is the institution of bundled payments—the grouping of multiple services into one “episode” for payment purposes. An episode might include inpatient hospitalization for pneumonia, for example, or the grouping of surgery with post-discharge care. In obstetrics, all pregnancy care could be grouped into one episode. The concept behind bundled payments is to provide incentives to institutions and providers to delivery higher-quality, more efficient, and less costly care.

If bundled payments become the reality for obstetric care in the future, how will that affect the way we care for our patients? Instead of blindly ordering all available tests, we need to consider thoroughly whether the patient truly needs a test to improve pregnancy outcomes. We also need to consider whether other measures might be avoided safely to keep costs within the bundle. A few examples:

 

• Is a screening fetal echocardiogram really necessary in a diabetic woman if the ultrasound anatomy scan is sufficient to rule out any cardiac anomaly that might require intervention in the delivery room?
• How will we integrate the expense of cell-free fetal DNA aneuploidy testing and microarray analysis, not to mention the extended counseling sessions that will be necessary to explain findings of uncertain clinical significance, into the bundle? Will “low-risk” patients need to pay out of pocket?

 

 

• Will a second ultrasound scan to visualize the fetal spine in a patient with a normal alpha-fetoprotein level be included in the bundle or paid for by the patient?

These issues may seem trivial, but we can no longer afford to order every test available. We will need to spend more time examining and counseling our patients so that they feel they are still getting the best care possible.

We want to hear from you! Tell us what you think.

Medical students learn early in their education that alcohol is a teratogen. Despite this widespread knowledge, many obstetricians counsel patients about the safety of low doses of alcohol in pregnancy.¹ Indeed, the Royal College of Obstetricians and Gynaecologists’ position on this is, “while the safest approach may be to avoid any alcohol during pregnancy, it remains the case that there is no evidence of harm from low levels of alcohol consumption, defined as no more than one or two units of alcohol once or twice a week.”²

Like many providers, I was aware of this controversy, but it became truly personal when a beloved family member was diagnosed with fetal alcohol syndrome (FAS). In this paper, I will review some of the controversy regarding alcohol in pregnancy, highlight findings from the literature, provide tools for prevention, and identify new developments regarding this devastating, preventable condition.

Charlie

To know my nephew Charlie is to fall in love with my nephew Charlie. One of the happiest moments of my life was when I learned my brother and sister-in-law had adopted twins from Kazakhstan. When my little niece and nephew started their new life in the United States, certain medical issues seemed to merit additional attention. Although both were very small for their age and required significant nutritional support, Charlie seemed to be a bit more rambunctious and required additional supervision.

The children were fortunate enough to have incredibly loving, dedicated parents, who have access to exceptional medical care as residents of Philadelphia, Pennsylvania. After extensive testing, it became clear what was causing Charlie’s developmental delay; his pediatric team made the diagnosis of FAS. My brother and sister-in-law became incredibly well-read about this challenging disorder, and threw themselves into national advocacy work to help prevent this unnecessary tragedy.

Recent data point to teratogenicity, but media confuse the issue

Some recent media coverage³ of celebrities who apparently drank while pregnant was in response to an article in the Journal of Epidemiology and Community Health.⁴ The authors of this study concluded that, “at age 5 years, cohort members born to mothers who drank up to one to two drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioral difficulties or cognitive deficits, compared with children of mothers in the not-in-pregnancy group.”

This is certainly not the first occasion the popular press has covered a published study that seems to indicate no ill effects of alcohol use in pregnancy. A 2008 report by Kelly and colleagues,⁵ and its subsequent media coverage, prompted the Fetal Alcohol Spectrum Disorders Study Group to state that the panel of experts was “alarmed” by recent newspaper reports suggesting that light drinking during pregnancy may be beneficial for an unborn child.⁶ They noted misleading and irresponsible media reports of the findings, which suggested that 3-year-old children whose mothers drank “lightly” during pregnancy were not at risk for certain behavioral problems.

What the study authors proceeded to note, however (that the media did not mention), was that the light drinkers in their study had socioeconomic advantages, compared with nondrinkers.⁵ (Advantaged economic status is established to be beneficial for childhood development.) They also noted that the study involved preschool-aged children, stating “Generally the adverse effects of light drinking during pregnancy are subtle and may go undetected in young children. However, other group studies of more moderate or ‘social’ drinking levels during pregnancy have shown an adverse impact on multiple aspects of development through adolescence and young adulthood, even when important environmental factors are taken into account.” A sentence I thought was most compelling in their statement was, “It is an inconvenient fact of life that alcohol is a teratogen.” Now, this fact is well supported in the literature.⁷

There are animal studies regarding the use of “low-dose” or “moderate” alcohol in pregnancy that demonstrate adverse behavioral outcomes with exposure to even small doses of alcohol.^8,9 It is an American tragedy that, according to the Centers for Disease Control and Prevention (CDC), rates of FAS in this country range from 0.2 to 2.0 cases per 1,000 live births. Indeed, the rates of fetal alcohol spectrum disorders (FASD) might be at least three times this rate.¹⁰ As is the case with other disorders, there are health disparities regarding the prevalence of this condition as well.¹¹

FAS: A long history of preventable disease

1973: Identified. FAS was first described in a 1973 Lancet report, “Pattern of malformation in offspring of chronic alcoholic mothers.”¹²

1996: Call for prevention. In 1995, the US Surgeon General issued a statement regarding alcohol use in pregnancy, noting, “We do not know what, if any, amount of alcohol is safe.”¹³ In 1996, the Institute of Medicine released a paper calling FAS and FASD “completely preventable birth defects and neurodevelopmental abnormalities.”¹⁴

 

2000: The troubling effects gathered. The American Academy of Pediatrics (AAP) published a monograph on FAS in 2000, defining it as a constellation of physical, behavioral, and cognitive abnormalities.¹⁵

These features classically define FAS:

• dysmorphic facial features
• prenatal and postnatal growth abnormalities
• mental retardation.

Approximately 80% of children with this condition have:

• microcephaly
• behavioral abnormalities.

As many as 50% of affected children also exhibit:

• poor coordination
• hypotonia
• attention-deficit hyperactivity disorder
• decreased adipose tissue
• identifiable facial anomalies (such as maxillary hypoplasia, cleft palate, and micrognathia).

Also common:

• cardiac defects
• hemangiomas
• eye or ear abnormalities.

The AAP further noted that data current to the time (and still true today) did not support the concept of a safe level of alcohol consumption by pregnant women below which no damage to a fetus will occur.¹⁵

Alcohol intake during pregnancy puts the fetus at risk for cognitive and neuropsychological impairment and physical abnormalities, including dysmorphic facial features (such as micrognathia), restricted prenatal growth, cardiac defects, and eye and ear abnormalities. There is no threshold dose of alcohol that is safe during pregnancy, according to the American College of Obstetricians and Gynecologists.

Despite the knowledge we’ve gained, FAS persists

According to a 2006–2010 CDC analysis involving more than 345,000 women of reproductive age from all 50 states, 7.6% of pregnant women reported alcohol use and 1.4% (or 1 in 71) reported binge drinking (defined, respectively, as at least one alcoholic drink and four or more alcoholic drinks on one occasion in the past 30 days).¹⁶ The highest prevalence of obstetric alcohol consumption occurs in women who are:

• aged 35 to 44 years
• white
• college graduates
• employed.

The problem may be bigger than reported. The incidences of alcohol and binge drinking found in the CDC report include women’s self-report—but women drink alcohol without knowing they’re pregnant. Only 40% of women realize they’re pregnant at 4 weeks of gestation, a critical time for organogenesis, and approximately half of all births are unplanned.⁹

When my brother and sister-in law adopted my beautiful niece and nephew, they were very aware of the risk for conditions like FAS. In an evaluation of 71 children adopted from Eastern Europe at 5 years of age, FAS was diagnosed in 30% of children and “partial FAS” in another 9%.¹⁷ Birth defects attributed to alcohol were present in 11% of the children.

Are women’s health providers up to date on FAS education?

In recognition of alcohol’s potentially life-altering consequences for the developing fetus, the American College of Obstetricians and Gynecologists (ACOG) produced an FASD prevention tool kit in 2006 and published a 2011 committee opinion on at-risk drinking and alcohol dependence and their implications for obstetrics and gynecology.^18,19 Both guidelines direct clinicians to advise patients to abstain from alcohol during pregnancy.

Results from a 2010 survey of 800 ACOG fellows revealed that only 78% of obstetricians advised abstinence from alcohol during pregnancy. Fifty-eight percent of respondents did not use a validated screening tool for alcohol use in their pregnant patients, and only 72% felt prepared to screen for risky or hazardous drinking.¹⁹ (Most were unaware of the ACOG tool kit, which had been published several years earlier.)

In a survey of pediatricians, obstetricians, and family physicians, clinicians said that about 67% of their patients asked about alcohol use in pregnancy, with about 2% of those patients specifically mentioning FAS. About 41% of these same physicians erroneously placed the threshold for FAS at one to three drinks per day,²⁰ when in fact there is no threshold of drinking that has been proven to be safe.

A survey of 1,000 actively practicing ACOG fellows revealed that, while 97% of obstetricians routinely asked their patients about alcohol use, only 20% of providers reported to their patients that abstinence was safest, and 4% of providers didn’t believe that consumption of eight or more drinks weekly posed fetal risk.²¹

How can we educate our patients about the dangers of alcohol in pregnancy?

Fetal death. A recent Danish study of 79,216 pregnant women revealed that 45% had consumed some alcohol during pregnancy. Two percent reported at least four drinks per week, and 25% admitted to binge drinking during pregnancy. Term infants born to women in the latter two groups had increased neonatal mortality, with hazard ratios of 3.56 (95% confidence interval [CI], 1.15–8.43) and 2.69 (95% CI, 1.27–5.69), respectively.²²

Decreased cognitive status. A study by Willford and colleagues evaluated the relationship between prenatal alcohol exposure and cognitive status of 1,360 10-year-old children.²³ The authors utilized the Stanford-Binet Intelligence Test, including the composite scores and verbal, abstract/visual, quantitative, and short-term memory scores. After controlling for other variables, among African American offspring they found that, for each additional drink, the average composite score decreased by 1.9 points. This difference was more striking for second-trimester use, and was significant even for one drink daily versus abstention from alcohol.

 

Impaired neuropsychological development. Another study evaluating light to moderate amounts of prenatal alcohol exposure in 10- and 11-year-old children found significantly worse scores regarding a number of neuropsychological developmental assessments.²⁴

No threshold dose of causation. Results of a 2012 prospective study in California, with data collected on 992 subjects from 1978 until 2005, revealed that many physical FAS features, including microcephaly, smooth philtrum, and thin vermillion border; reduced birth length; and reduced birth weight, were associated with alcohol exposure at specific gestational ages, and were dose-related.²⁵ This paper didn’t reveal any evidence of a threshold dose of causation.

Neurobehavioral outcomes of FAS are not always considered

Another recent study that the media recently highlighted as finding “no association between low or moderate prenatal alcohol exposure and birth defects” was by O’Leary and colleagues.²⁶ Like other similarly limited studies, this one involved only children younger than 6 years and didn’t assess any of the important neurobehavioral outcomes of FAS.

FAS encompasses much more than visible birth defects. As the aforementioned ACOG tool kit stated, “For every child born with FAS, many more children are born with neurobehavioral deficits caused by alcohol exposure but without the physical characteristics of FAS.”

The costs of FAS are felt with dollars, too

The financial cost to our nation is extraordinary. In 1991, Abel and Sokol estimated the incremental annual cost of treating FAS at nearly $75 million, with about three-quarters of that cost associated with FAS cases involving mental retardation.²⁷

A 2002 assessment estimated the lifetime cost for each individual with FAS (adjusting for the change in the cost of medical care services, lost productivity, and inflation) at $2 million. This figure consists of $1.6 million for medical treatment, special education, and residential care for persons with mental retardation, and $0.4 million for productivity losses.²⁸

Where human studies fall short, animal studies can help elucidate causation

Unquestionably, there are flaws in the existing literature on the causation of FAS. Many studies rely on self-reporting by pregnant women, and underreporting in these cases is a real concern. There often are other confounders potentially negatively affecting fetal development, making it difficult to differentiate causation. The animal studies that don’t share these limitations do suggest a causal relationship between antenatal alcohol exposure and poor obstetric outcomes, however.²⁹ These studies suggest mechanisms such as altered gene expression, oxidative stress, and apoptosis (programmed cell death).³⁰

Warren, Hewitt, and Thomas describe how intrauterine alcohol exposure interferes with the function of L1CAM, the L1 cell-adhesion molecule.³¹ They noted that just one drink could interfere with the ability of L1CAM to mediate cell adhesion and axonal growth. Prenatal alcohol exposure is also thought to contribute to interference in neurotransmitter and N-methyl-D-aspartate receptor coupling, which may have potential therapeutic implications.³²

Considerations in FAS identification and treatment

There is a potential to identify alcohol exposure in the womb. The majority of ingested alcohol is eventually converted to carbon dioxide and water in both maternal and fetal circulations, which has hampered the identification of biomarkers for clinical use in FAS. Fatty acid ethyl esters (FAEEs), nonoxidative metabolites of ethanol, may prove to be such markers.³³ FAEEs have been measured in a variety of tissues, including blood and meconium. FAEEs can be measured in both neonatal and maternal hair samples.

A study evaluating the utility of such testing in 324 at-risk pregnancies revealed 90% sensitivity and 90% specificity for identifying “excessive drinking” using a cutoff of 0.5 ng/mg.³⁴

Research shows potential therapeutic approaches during pregnancy. While the use of biomarkers has the potential to assist with the identification of at-risk newborns, it merely identifies past alcohol use; it doesn’t necessarily permit identification and prevention of the known negative pediatric sequelae. Preliminary animal studies reveal the potential benefit of neuroprotective peptides to prevent brain damage in alcohol-exposed mice.³⁵ Further research is ongoing.

Treatment: The earlier the better

Early diagnosis and a positive environment improve outcomes. It is well established that early intervention improves outcomes. One comprehensive review of 415 patients with FAS noted troubling outcomes in general for adolescents and adults.³⁶ Over their life spans, the prevalence of such outcomes was:

• 61% for disrupted school experiences
• 60% for trouble with the law
• 50% for confinement (in detention, jail, prison, or a psychiatric or alcohol/drug inpatient setting)
• 49% for inappropriate sexual behaviors on repeated occasions
• 35% for alcohol/drug problems.

The odds of escaping these adverse life outcomes are increased up to fourfold when the individual receives a FAS or FASD diagnosis at an earlier age and is reared in a stable environment.³⁶

 

Barrier to treatment: A mother’s guilt. One of the challenges I’ve learned from my sister-in-law is the stigma mothers face when they bring their child in for services once the diagnosis of FAS is suspected. While adoptive mothers obviously can’t be held accountable for the intrauterine environment to which a fetus is exposed, the same can’t be said of biologic mothers. Therefore, there is a real risk that a mother who is unwilling or unable to face the potentially devastating news that her baby’s issues might be related to choices she made during pregnancy, might not bring her child in for necessary assessment and treatment. Therefore, prevention is a key proponent of treatment.

Prevent FAS: Provide contraception, screen for alcohol use, intervene

While ObGyns aren’t likely to diagnose many children with FAS, we are in an excellent position to try to prevent this tragedy through our counseling of reproductive-aged women. I suspect that most obstetricians spend a considerable amount of time discussing much less frequent obstetric sequelae, such as listeriosis, in the prenatal care setting. Validated alcohol screening tools take moments to administer, and once patients who might have alcohol problems are identified, either a serious discussion about contraception or an honest discussion of FAS may be appropriate. There have been a number of screening tools developed.

The CAGE screen is frequently taught in medical schools, but it isn’t as sensitive for women or minorities.¹⁹

The T-ACE (Tolerance, Annoyed, Cut Down, Eye-opener) tool involves four questions that take less than 1 minute to administer (FIGURE 1).³⁹

TWEAK is another potential tool identified by Russell and colleagues (Tolerance, Worry, Eye opener, Amnesia, and Cut down in drinking).³⁹ Other methods utilized include an AUDIT screen and a CRAFFT screen.⁴⁰ Regardless of which tool is utilized, screening is not time-consuming and is better than merely inquiring about alcohol consumption in general.

FIGURE 1 T-ACE validated alcohol screening tool
Source: American College of Obstetricians and Gynecologists. At risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008;112(6):1449–1460.

When alcohol use is found, intervene

Once patients with at-risk behavior are identified, obstetric staff should offer brief interventions to influence problem drinking. Miller and Sanchez summarized the key elements that were most successful in these programs with the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy (FIGURE 2).⁴¹ This approach has been formally evaluated in the CDC’s multisite pilot study entitled Project CHOICES.⁴²

In this motivational intervention, sexually active, fertile women of reproductive age underwent up to four motivational counseling sessions and one visit to a provider. At 6 months, 69% of women reduced their risk for an alcohol-exposed pregnancy—although the women who drank the least amount had the greatest benefit, primarily by choosing effective contraception, but also by reducing alcohol intake.

FIGURE 2 FRAMES model to deliver brief interventions
Source: American College of Obstetricians and Gynecologists. Drinking and reproductive health: A fetal alcohol spectrum disorders prevention tool kit. Washington, DC: ACOG; 2006.

A single, brief intervention is effective in already-pregnant women. Chang and colleagues conducted a randomized trial of a single-session brief intervention given to pregnant women with positive T-ACE screens and their partners (FIGURE 3).⁴³ Either the study nurse or physician participated in the intervention, and each single session took 25 minutes on average. The pregnant women with the highest level of alcohol use reduced their drinking the most, and this effect was even larger when their partners participated. Other studies of brief interventions showed similar benefits.^44,45

Another study evaluating a brief intervention involving training of health-care providers to improve screening rates revealed improved detection and therapy among at-risk patients.⁴⁶

FIGURE 3 Single session, 25-minute intervention for patients and their partners
Source: Chang G, McNamara T, Orav J, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105(5 Pt 1):991–998.

FAS prevention begins with routine counseling and contraception

Although FAS is often thought of in relation to obstetric populations, appointments for preconception counseling or routine health maintenance among women of reproductive age are an essential tool in FAS prevention. As previously mentioned, since approximately half of all pregnancies in this country are unplanned, long-acting reversible contraception is widely available to facilitate improved family planning.

Other contraceptive options also should be discussed. ACOG has teamed up with the CDC to develop a phone app for providers to use at the patient’s bedside to assist with identification and treatment of women at risk for alcohol use during pregnancy.⁴⁷

The stakes are high, it’s time to step up

 

As obstetricians, we are powerless to prevent many conditions—such as vasa previa, acute fatty liver of pregnancy, and amniotic band syndrome. FAS is 100% preventable.

There aren’t that many proven teratogens in our profession, and there are none that involve behavior that is more socially acceptable than alcohol consumption. It is time for our profession to encourage women to appreciate how small a percentage of one’s life is spent pregnant, how many more years there are to enjoy an occasional cocktail, and how very high the stakes are during this important period of their lives. Oh, how I wish someone had been able to communicate all of this to sweet Charlie’s biologic mother. I am so grateful he’s getting the exceptional care he’s getting and very optimistic regarding his future. I only hope others in his situation are given the same opportunities.

We want to hear from you! Tell us what you think.

Medical students learn early in their education that alcohol is a teratogen. Despite this widespread knowledge, many obstetricians counsel patients about the safety of low doses of alcohol in pregnancy.¹ Indeed, the Royal College of Obstetricians and Gynaecologists’ position on this is, “while the safest approach may be to avoid any alcohol during pregnancy, it remains the case that there is no evidence of harm from low levels of alcohol consumption, defined as no more than one or two units of alcohol once or twice a week.”²

Like many providers, I was aware of this controversy, but it became truly personal when a beloved family member was diagnosed with fetal alcohol syndrome (FAS). In this paper, I will review some of the controversy regarding alcohol in pregnancy, highlight findings from the literature, provide tools for prevention, and identify new developments regarding this devastating, preventable condition.

Charlie

To know my nephew Charlie is to fall in love with my nephew Charlie. One of the happiest moments of my life was when I learned my brother and sister-in-law had adopted twins from Kazakhstan. When my little niece and nephew started their new life in the United States, certain medical issues seemed to merit additional attention. Although both were very small for their age and required significant nutritional support, Charlie seemed to be a bit more rambunctious and required additional supervision.

The children were fortunate enough to have incredibly loving, dedicated parents, who have access to exceptional medical care as residents of Philadelphia, Pennsylvania. After extensive testing, it became clear what was causing Charlie’s developmental delay; his pediatric team made the diagnosis of FAS. My brother and sister-in-law became incredibly well-read about this challenging disorder, and threw themselves into national advocacy work to help prevent this unnecessary tragedy.

Recent data point to teratogenicity, but media confuse the issue

Some recent media coverage³ of celebrities who apparently drank while pregnant was in response to an article in the Journal of Epidemiology and Community Health.⁴ The authors of this study concluded that, “at age 5 years, cohort members born to mothers who drank up to one to two drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioral difficulties or cognitive deficits, compared with children of mothers in the not-in-pregnancy group.”

This is certainly not the first occasion the popular press has covered a published study that seems to indicate no ill effects of alcohol use in pregnancy. A 2008 report by Kelly and colleagues,⁵ and its subsequent media coverage, prompted the Fetal Alcohol Spectrum Disorders Study Group to state that the panel of experts was “alarmed” by recent newspaper reports suggesting that light drinking during pregnancy may be beneficial for an unborn child.⁶ They noted misleading and irresponsible media reports of the findings, which suggested that 3-year-old children whose mothers drank “lightly” during pregnancy were not at risk for certain behavioral problems.

What the study authors proceeded to note, however (that the media did not mention), was that the light drinkers in their study had socioeconomic advantages, compared with nondrinkers.⁵ (Advantaged economic status is established to be beneficial for childhood development.) They also noted that the study involved preschool-aged children, stating “Generally the adverse effects of light drinking during pregnancy are subtle and may go undetected in young children. However, other group studies of more moderate or ‘social’ drinking levels during pregnancy have shown an adverse impact on multiple aspects of development through adolescence and young adulthood, even when important environmental factors are taken into account.” A sentence I thought was most compelling in their statement was, “It is an inconvenient fact of life that alcohol is a teratogen.” Now, this fact is well supported in the literature.⁷

There are animal studies regarding the use of “low-dose” or “moderate” alcohol in pregnancy that demonstrate adverse behavioral outcomes with exposure to even small doses of alcohol.^8,9 It is an American tragedy that, according to the Centers for Disease Control and Prevention (CDC), rates of FAS in this country range from 0.2 to 2.0 cases per 1,000 live births. Indeed, the rates of fetal alcohol spectrum disorders (FASD) might be at least three times this rate.¹⁰ As is the case with other disorders, there are health disparities regarding the prevalence of this condition as well.¹¹

FAS: A long history of preventable disease

1973: Identified. FAS was first described in a 1973 Lancet report, “Pattern of malformation in offspring of chronic alcoholic mothers.”¹²

1996: Call for prevention. In 1995, the US Surgeon General issued a statement regarding alcohol use in pregnancy, noting, “We do not know what, if any, amount of alcohol is safe.”¹³ In 1996, the Institute of Medicine released a paper calling FAS and FASD “completely preventable birth defects and neurodevelopmental abnormalities.”¹⁴

 

2000: The troubling effects gathered. The American Academy of Pediatrics (AAP) published a monograph on FAS in 2000, defining it as a constellation of physical, behavioral, and cognitive abnormalities.¹⁵

These features classically define FAS:

• dysmorphic facial features
• prenatal and postnatal growth abnormalities
• mental retardation.

Approximately 80% of children with this condition have:

• microcephaly
• behavioral abnormalities.

As many as 50% of affected children also exhibit:

• poor coordination
• hypotonia
• attention-deficit hyperactivity disorder
• decreased adipose tissue
• identifiable facial anomalies (such as maxillary hypoplasia, cleft palate, and micrognathia).

Also common:

• cardiac defects
• hemangiomas
• eye or ear abnormalities.

The AAP further noted that data current to the time (and still true today) did not support the concept of a safe level of alcohol consumption by pregnant women below which no damage to a fetus will occur.¹⁵

Alcohol intake during pregnancy puts the fetus at risk for cognitive and neuropsychological impairment and physical abnormalities, including dysmorphic facial features (such as micrognathia), restricted prenatal growth, cardiac defects, and eye and ear abnormalities. There is no threshold dose of alcohol that is safe during pregnancy, according to the American College of Obstetricians and Gynecologists.

Despite the knowledge we’ve gained, FAS persists

According to a 2006–2010 CDC analysis involving more than 345,000 women of reproductive age from all 50 states, 7.6% of pregnant women reported alcohol use and 1.4% (or 1 in 71) reported binge drinking (defined, respectively, as at least one alcoholic drink and four or more alcoholic drinks on one occasion in the past 30 days).¹⁶ The highest prevalence of obstetric alcohol consumption occurs in women who are:

• aged 35 to 44 years
• white
• college graduates
• employed.

The problem may be bigger than reported. The incidences of alcohol and binge drinking found in the CDC report include women’s self-report—but women drink alcohol without knowing they’re pregnant. Only 40% of women realize they’re pregnant at 4 weeks of gestation, a critical time for organogenesis, and approximately half of all births are unplanned.⁹

When my brother and sister-in law adopted my beautiful niece and nephew, they were very aware of the risk for conditions like FAS. In an evaluation of 71 children adopted from Eastern Europe at 5 years of age, FAS was diagnosed in 30% of children and “partial FAS” in another 9%.¹⁷ Birth defects attributed to alcohol were present in 11% of the children.

Are women’s health providers up to date on FAS education?

In recognition of alcohol’s potentially life-altering consequences for the developing fetus, the American College of Obstetricians and Gynecologists (ACOG) produced an FASD prevention tool kit in 2006 and published a 2011 committee opinion on at-risk drinking and alcohol dependence and their implications for obstetrics and gynecology.^18,19 Both guidelines direct clinicians to advise patients to abstain from alcohol during pregnancy.

Results from a 2010 survey of 800 ACOG fellows revealed that only 78% of obstetricians advised abstinence from alcohol during pregnancy. Fifty-eight percent of respondents did not use a validated screening tool for alcohol use in their pregnant patients, and only 72% felt prepared to screen for risky or hazardous drinking.¹⁹ (Most were unaware of the ACOG tool kit, which had been published several years earlier.)

In a survey of pediatricians, obstetricians, and family physicians, clinicians said that about 67% of their patients asked about alcohol use in pregnancy, with about 2% of those patients specifically mentioning FAS. About 41% of these same physicians erroneously placed the threshold for FAS at one to three drinks per day,²⁰ when in fact there is no threshold of drinking that has been proven to be safe.

A survey of 1,000 actively practicing ACOG fellows revealed that, while 97% of obstetricians routinely asked their patients about alcohol use, only 20% of providers reported to their patients that abstinence was safest, and 4% of providers didn’t believe that consumption of eight or more drinks weekly posed fetal risk.²¹

How can we educate our patients about the dangers of alcohol in pregnancy?

Fetal death. A recent Danish study of 79,216 pregnant women revealed that 45% had consumed some alcohol during pregnancy. Two percent reported at least four drinks per week, and 25% admitted to binge drinking during pregnancy. Term infants born to women in the latter two groups had increased neonatal mortality, with hazard ratios of 3.56 (95% confidence interval [CI], 1.15–8.43) and 2.69 (95% CI, 1.27–5.69), respectively.²²

Decreased cognitive status. A study by Willford and colleagues evaluated the relationship between prenatal alcohol exposure and cognitive status of 1,360 10-year-old children.²³ The authors utilized the Stanford-Binet Intelligence Test, including the composite scores and verbal, abstract/visual, quantitative, and short-term memory scores. After controlling for other variables, among African American offspring they found that, for each additional drink, the average composite score decreased by 1.9 points. This difference was more striking for second-trimester use, and was significant even for one drink daily versus abstention from alcohol.

 

Impaired neuropsychological development. Another study evaluating light to moderate amounts of prenatal alcohol exposure in 10- and 11-year-old children found significantly worse scores regarding a number of neuropsychological developmental assessments.²⁴

No threshold dose of causation. Results of a 2012 prospective study in California, with data collected on 992 subjects from 1978 until 2005, revealed that many physical FAS features, including microcephaly, smooth philtrum, and thin vermillion border; reduced birth length; and reduced birth weight, were associated with alcohol exposure at specific gestational ages, and were dose-related.²⁵ This paper didn’t reveal any evidence of a threshold dose of causation.

Neurobehavioral outcomes of FAS are not always considered

Another recent study that the media recently highlighted as finding “no association between low or moderate prenatal alcohol exposure and birth defects” was by O’Leary and colleagues.²⁶ Like other similarly limited studies, this one involved only children younger than 6 years and didn’t assess any of the important neurobehavioral outcomes of FAS.

FAS encompasses much more than visible birth defects. As the aforementioned ACOG tool kit stated, “For every child born with FAS, many more children are born with neurobehavioral deficits caused by alcohol exposure but without the physical characteristics of FAS.”

The costs of FAS are felt with dollars, too

The financial cost to our nation is extraordinary. In 1991, Abel and Sokol estimated the incremental annual cost of treating FAS at nearly $75 million, with about three-quarters of that cost associated with FAS cases involving mental retardation.²⁷

A 2002 assessment estimated the lifetime cost for each individual with FAS (adjusting for the change in the cost of medical care services, lost productivity, and inflation) at $2 million. This figure consists of $1.6 million for medical treatment, special education, and residential care for persons with mental retardation, and $0.4 million for productivity losses.²⁸

Where human studies fall short, animal studies can help elucidate causation

Unquestionably, there are flaws in the existing literature on the causation of FAS. Many studies rely on self-reporting by pregnant women, and underreporting in these cases is a real concern. There often are other confounders potentially negatively affecting fetal development, making it difficult to differentiate causation. The animal studies that don’t share these limitations do suggest a causal relationship between antenatal alcohol exposure and poor obstetric outcomes, however.²⁹ These studies suggest mechanisms such as altered gene expression, oxidative stress, and apoptosis (programmed cell death).³⁰

Warren, Hewitt, and Thomas describe how intrauterine alcohol exposure interferes with the function of L1CAM, the L1 cell-adhesion molecule.³¹ They noted that just one drink could interfere with the ability of L1CAM to mediate cell adhesion and axonal growth. Prenatal alcohol exposure is also thought to contribute to interference in neurotransmitter and N-methyl-D-aspartate receptor coupling, which may have potential therapeutic implications.³²

Considerations in FAS identification and treatment

There is a potential to identify alcohol exposure in the womb. The majority of ingested alcohol is eventually converted to carbon dioxide and water in both maternal and fetal circulations, which has hampered the identification of biomarkers for clinical use in FAS. Fatty acid ethyl esters (FAEEs), nonoxidative metabolites of ethanol, may prove to be such markers.³³ FAEEs have been measured in a variety of tissues, including blood and meconium. FAEEs can be measured in both neonatal and maternal hair samples.

A study evaluating the utility of such testing in 324 at-risk pregnancies revealed 90% sensitivity and 90% specificity for identifying “excessive drinking” using a cutoff of 0.5 ng/mg.³⁴

Research shows potential therapeutic approaches during pregnancy. While the use of biomarkers has the potential to assist with the identification of at-risk newborns, it merely identifies past alcohol use; it doesn’t necessarily permit identification and prevention of the known negative pediatric sequelae. Preliminary animal studies reveal the potential benefit of neuroprotective peptides to prevent brain damage in alcohol-exposed mice.³⁵ Further research is ongoing.

Treatment: The earlier the better

Early diagnosis and a positive environment improve outcomes. It is well established that early intervention improves outcomes. One comprehensive review of 415 patients with FAS noted troubling outcomes in general for adolescents and adults.³⁶ Over their life spans, the prevalence of such outcomes was:

• 61% for disrupted school experiences
• 60% for trouble with the law
• 50% for confinement (in detention, jail, prison, or a psychiatric or alcohol/drug inpatient setting)
• 49% for inappropriate sexual behaviors on repeated occasions
• 35% for alcohol/drug problems.

The odds of escaping these adverse life outcomes are increased up to fourfold when the individual receives a FAS or FASD diagnosis at an earlier age and is reared in a stable environment.³⁶

 

Barrier to treatment: A mother’s guilt. One of the challenges I’ve learned from my sister-in-law is the stigma mothers face when they bring their child in for services once the diagnosis of FAS is suspected. While adoptive mothers obviously can’t be held accountable for the intrauterine environment to which a fetus is exposed, the same can’t be said of biologic mothers. Therefore, there is a real risk that a mother who is unwilling or unable to face the potentially devastating news that her baby’s issues might be related to choices she made during pregnancy, might not bring her child in for necessary assessment and treatment. Therefore, prevention is a key proponent of treatment.

Prevent FAS: Provide contraception, screen for alcohol use, intervene

While ObGyns aren’t likely to diagnose many children with FAS, we are in an excellent position to try to prevent this tragedy through our counseling of reproductive-aged women. I suspect that most obstetricians spend a considerable amount of time discussing much less frequent obstetric sequelae, such as listeriosis, in the prenatal care setting. Validated alcohol screening tools take moments to administer, and once patients who might have alcohol problems are identified, either a serious discussion about contraception or an honest discussion of FAS may be appropriate. There have been a number of screening tools developed.

The CAGE screen is frequently taught in medical schools, but it isn’t as sensitive for women or minorities.¹⁹

The T-ACE (Tolerance, Annoyed, Cut Down, Eye-opener) tool involves four questions that take less than 1 minute to administer (FIGURE 1).³⁹

TWEAK is another potential tool identified by Russell and colleagues (Tolerance, Worry, Eye opener, Amnesia, and Cut down in drinking).³⁹ Other methods utilized include an AUDIT screen and a CRAFFT screen.⁴⁰ Regardless of which tool is utilized, screening is not time-consuming and is better than merely inquiring about alcohol consumption in general.

FIGURE 1 T-ACE validated alcohol screening tool
Source: American College of Obstetricians and Gynecologists. At risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008;112(6):1449–1460.

When alcohol use is found, intervene

Once patients with at-risk behavior are identified, obstetric staff should offer brief interventions to influence problem drinking. Miller and Sanchez summarized the key elements that were most successful in these programs with the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy (FIGURE 2).⁴¹ This approach has been formally evaluated in the CDC’s multisite pilot study entitled Project CHOICES.⁴²

In this motivational intervention, sexually active, fertile women of reproductive age underwent up to four motivational counseling sessions and one visit to a provider. At 6 months, 69% of women reduced their risk for an alcohol-exposed pregnancy—although the women who drank the least amount had the greatest benefit, primarily by choosing effective contraception, but also by reducing alcohol intake.

FIGURE 2 FRAMES model to deliver brief interventions
Source: American College of Obstetricians and Gynecologists. Drinking and reproductive health: A fetal alcohol spectrum disorders prevention tool kit. Washington, DC: ACOG; 2006.

A single, brief intervention is effective in already-pregnant women. Chang and colleagues conducted a randomized trial of a single-session brief intervention given to pregnant women with positive T-ACE screens and their partners (FIGURE 3).⁴³ Either the study nurse or physician participated in the intervention, and each single session took 25 minutes on average. The pregnant women with the highest level of alcohol use reduced their drinking the most, and this effect was even larger when their partners participated. Other studies of brief interventions showed similar benefits.^44,45

Another study evaluating a brief intervention involving training of health-care providers to improve screening rates revealed improved detection and therapy among at-risk patients.⁴⁶

FIGURE 3 Single session, 25-minute intervention for patients and their partners
Source: Chang G, McNamara T, Orav J, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105(5 Pt 1):991–998.

FAS prevention begins with routine counseling and contraception

Although FAS is often thought of in relation to obstetric populations, appointments for preconception counseling or routine health maintenance among women of reproductive age are an essential tool in FAS prevention. As previously mentioned, since approximately half of all pregnancies in this country are unplanned, long-acting reversible contraception is widely available to facilitate improved family planning.

Other contraceptive options also should be discussed. ACOG has teamed up with the CDC to develop a phone app for providers to use at the patient’s bedside to assist with identification and treatment of women at risk for alcohol use during pregnancy.⁴⁷

The stakes are high, it’s time to step up

 

As obstetricians, we are powerless to prevent many conditions—such as vasa previa, acute fatty liver of pregnancy, and amniotic band syndrome. FAS is 100% preventable.

There aren’t that many proven teratogens in our profession, and there are none that involve behavior that is more socially acceptable than alcohol consumption. It is time for our profession to encourage women to appreciate how small a percentage of one’s life is spent pregnant, how many more years there are to enjoy an occasional cocktail, and how very high the stakes are during this important period of their lives. Oh, how I wish someone had been able to communicate all of this to sweet Charlie’s biologic mother. I am so grateful he’s getting the exceptional care he’s getting and very optimistic regarding his future. I only hope others in his situation are given the same opportunities.

We want to hear from you! Tell us what you think.

Medical students learn early in their education that alcohol is a teratogen. Despite this widespread knowledge, many obstetricians counsel patients about the safety of low doses of alcohol in pregnancy.¹ Indeed, the Royal College of Obstetricians and Gynaecologists’ position on this is, “while the safest approach may be to avoid any alcohol during pregnancy, it remains the case that there is no evidence of harm from low levels of alcohol consumption, defined as no more than one or two units of alcohol once or twice a week.”²

Like many providers, I was aware of this controversy, but it became truly personal when a beloved family member was diagnosed with fetal alcohol syndrome (FAS). In this paper, I will review some of the controversy regarding alcohol in pregnancy, highlight findings from the literature, provide tools for prevention, and identify new developments regarding this devastating, preventable condition.

Charlie

To know my nephew Charlie is to fall in love with my nephew Charlie. One of the happiest moments of my life was when I learned my brother and sister-in-law had adopted twins from Kazakhstan. When my little niece and nephew started their new life in the United States, certain medical issues seemed to merit additional attention. Although both were very small for their age and required significant nutritional support, Charlie seemed to be a bit more rambunctious and required additional supervision.

The children were fortunate enough to have incredibly loving, dedicated parents, who have access to exceptional medical care as residents of Philadelphia, Pennsylvania. After extensive testing, it became clear what was causing Charlie’s developmental delay; his pediatric team made the diagnosis of FAS. My brother and sister-in-law became incredibly well-read about this challenging disorder, and threw themselves into national advocacy work to help prevent this unnecessary tragedy.

Recent data point to teratogenicity, but media confuse the issue

Some recent media coverage³ of celebrities who apparently drank while pregnant was in response to an article in the Journal of Epidemiology and Community Health.⁴ The authors of this study concluded that, “at age 5 years, cohort members born to mothers who drank up to one to two drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioral difficulties or cognitive deficits, compared with children of mothers in the not-in-pregnancy group.”

This is certainly not the first occasion the popular press has covered a published study that seems to indicate no ill effects of alcohol use in pregnancy. A 2008 report by Kelly and colleagues,⁵ and its subsequent media coverage, prompted the Fetal Alcohol Spectrum Disorders Study Group to state that the panel of experts was “alarmed” by recent newspaper reports suggesting that light drinking during pregnancy may be beneficial for an unborn child.⁶ They noted misleading and irresponsible media reports of the findings, which suggested that 3-year-old children whose mothers drank “lightly” during pregnancy were not at risk for certain behavioral problems.

What the study authors proceeded to note, however (that the media did not mention), was that the light drinkers in their study had socioeconomic advantages, compared with nondrinkers.⁵ (Advantaged economic status is established to be beneficial for childhood development.) They also noted that the study involved preschool-aged children, stating “Generally the adverse effects of light drinking during pregnancy are subtle and may go undetected in young children. However, other group studies of more moderate or ‘social’ drinking levels during pregnancy have shown an adverse impact on multiple aspects of development through adolescence and young adulthood, even when important environmental factors are taken into account.” A sentence I thought was most compelling in their statement was, “It is an inconvenient fact of life that alcohol is a teratogen.” Now, this fact is well supported in the literature.⁷

There are animal studies regarding the use of “low-dose” or “moderate” alcohol in pregnancy that demonstrate adverse behavioral outcomes with exposure to even small doses of alcohol.^8,9 It is an American tragedy that, according to the Centers for Disease Control and Prevention (CDC), rates of FAS in this country range from 0.2 to 2.0 cases per 1,000 live births. Indeed, the rates of fetal alcohol spectrum disorders (FASD) might be at least three times this rate.¹⁰ As is the case with other disorders, there are health disparities regarding the prevalence of this condition as well.¹¹

FAS: A long history of preventable disease

1973: Identified. FAS was first described in a 1973 Lancet report, “Pattern of malformation in offspring of chronic alcoholic mothers.”¹²

1996: Call for prevention. In 1995, the US Surgeon General issued a statement regarding alcohol use in pregnancy, noting, “We do not know what, if any, amount of alcohol is safe.”¹³ In 1996, the Institute of Medicine released a paper calling FAS and FASD “completely preventable birth defects and neurodevelopmental abnormalities.”¹⁴

 

2000: The troubling effects gathered. The American Academy of Pediatrics (AAP) published a monograph on FAS in 2000, defining it as a constellation of physical, behavioral, and cognitive abnormalities.¹⁵

These features classically define FAS:

• dysmorphic facial features
• prenatal and postnatal growth abnormalities
• mental retardation.

Approximately 80% of children with this condition have:

• microcephaly
• behavioral abnormalities.

As many as 50% of affected children also exhibit:

• poor coordination
• hypotonia
• attention-deficit hyperactivity disorder
• decreased adipose tissue
• identifiable facial anomalies (such as maxillary hypoplasia, cleft palate, and micrognathia).

Also common:

• cardiac defects
• hemangiomas
• eye or ear abnormalities.

The AAP further noted that data current to the time (and still true today) did not support the concept of a safe level of alcohol consumption by pregnant women below which no damage to a fetus will occur.¹⁵

Alcohol intake during pregnancy puts the fetus at risk for cognitive and neuropsychological impairment and physical abnormalities, including dysmorphic facial features (such as micrognathia), restricted prenatal growth, cardiac defects, and eye and ear abnormalities. There is no threshold dose of alcohol that is safe during pregnancy, according to the American College of Obstetricians and Gynecologists.

Despite the knowledge we’ve gained, FAS persists

According to a 2006–2010 CDC analysis involving more than 345,000 women of reproductive age from all 50 states, 7.6% of pregnant women reported alcohol use and 1.4% (or 1 in 71) reported binge drinking (defined, respectively, as at least one alcoholic drink and four or more alcoholic drinks on one occasion in the past 30 days).¹⁶ The highest prevalence of obstetric alcohol consumption occurs in women who are:

• aged 35 to 44 years
• white
• college graduates
• employed.

The problem may be bigger than reported. The incidences of alcohol and binge drinking found in the CDC report include women’s self-report—but women drink alcohol without knowing they’re pregnant. Only 40% of women realize they’re pregnant at 4 weeks of gestation, a critical time for organogenesis, and approximately half of all births are unplanned.⁹

When my brother and sister-in law adopted my beautiful niece and nephew, they were very aware of the risk for conditions like FAS. In an evaluation of 71 children adopted from Eastern Europe at 5 years of age, FAS was diagnosed in 30% of children and “partial FAS” in another 9%.¹⁷ Birth defects attributed to alcohol were present in 11% of the children.

Are women’s health providers up to date on FAS education?

In recognition of alcohol’s potentially life-altering consequences for the developing fetus, the American College of Obstetricians and Gynecologists (ACOG) produced an FASD prevention tool kit in 2006 and published a 2011 committee opinion on at-risk drinking and alcohol dependence and their implications for obstetrics and gynecology.^18,19 Both guidelines direct clinicians to advise patients to abstain from alcohol during pregnancy.

Results from a 2010 survey of 800 ACOG fellows revealed that only 78% of obstetricians advised abstinence from alcohol during pregnancy. Fifty-eight percent of respondents did not use a validated screening tool for alcohol use in their pregnant patients, and only 72% felt prepared to screen for risky or hazardous drinking.¹⁹ (Most were unaware of the ACOG tool kit, which had been published several years earlier.)

In a survey of pediatricians, obstetricians, and family physicians, clinicians said that about 67% of their patients asked about alcohol use in pregnancy, with about 2% of those patients specifically mentioning FAS. About 41% of these same physicians erroneously placed the threshold for FAS at one to three drinks per day,²⁰ when in fact there is no threshold of drinking that has been proven to be safe.

A survey of 1,000 actively practicing ACOG fellows revealed that, while 97% of obstetricians routinely asked their patients about alcohol use, only 20% of providers reported to their patients that abstinence was safest, and 4% of providers didn’t believe that consumption of eight or more drinks weekly posed fetal risk.²¹

How can we educate our patients about the dangers of alcohol in pregnancy?

Fetal death. A recent Danish study of 79,216 pregnant women revealed that 45% had consumed some alcohol during pregnancy. Two percent reported at least four drinks per week, and 25% admitted to binge drinking during pregnancy. Term infants born to women in the latter two groups had increased neonatal mortality, with hazard ratios of 3.56 (95% confidence interval [CI], 1.15–8.43) and 2.69 (95% CI, 1.27–5.69), respectively.²²

Decreased cognitive status. A study by Willford and colleagues evaluated the relationship between prenatal alcohol exposure and cognitive status of 1,360 10-year-old children.²³ The authors utilized the Stanford-Binet Intelligence Test, including the composite scores and verbal, abstract/visual, quantitative, and short-term memory scores. After controlling for other variables, among African American offspring they found that, for each additional drink, the average composite score decreased by 1.9 points. This difference was more striking for second-trimester use, and was significant even for one drink daily versus abstention from alcohol.

 

Impaired neuropsychological development. Another study evaluating light to moderate amounts of prenatal alcohol exposure in 10- and 11-year-old children found significantly worse scores regarding a number of neuropsychological developmental assessments.²⁴

No threshold dose of causation. Results of a 2012 prospective study in California, with data collected on 992 subjects from 1978 until 2005, revealed that many physical FAS features, including microcephaly, smooth philtrum, and thin vermillion border; reduced birth length; and reduced birth weight, were associated with alcohol exposure at specific gestational ages, and were dose-related.²⁵ This paper didn’t reveal any evidence of a threshold dose of causation.

Neurobehavioral outcomes of FAS are not always considered

Another recent study that the media recently highlighted as finding “no association between low or moderate prenatal alcohol exposure and birth defects” was by O’Leary and colleagues.²⁶ Like other similarly limited studies, this one involved only children younger than 6 years and didn’t assess any of the important neurobehavioral outcomes of FAS.

FAS encompasses much more than visible birth defects. As the aforementioned ACOG tool kit stated, “For every child born with FAS, many more children are born with neurobehavioral deficits caused by alcohol exposure but without the physical characteristics of FAS.”

The costs of FAS are felt with dollars, too

The financial cost to our nation is extraordinary. In 1991, Abel and Sokol estimated the incremental annual cost of treating FAS at nearly $75 million, with about three-quarters of that cost associated with FAS cases involving mental retardation.²⁷

A 2002 assessment estimated the lifetime cost for each individual with FAS (adjusting for the change in the cost of medical care services, lost productivity, and inflation) at $2 million. This figure consists of $1.6 million for medical treatment, special education, and residential care for persons with mental retardation, and $0.4 million for productivity losses.²⁸

Where human studies fall short, animal studies can help elucidate causation

Unquestionably, there are flaws in the existing literature on the causation of FAS. Many studies rely on self-reporting by pregnant women, and underreporting in these cases is a real concern. There often are other confounders potentially negatively affecting fetal development, making it difficult to differentiate causation. The animal studies that don’t share these limitations do suggest a causal relationship between antenatal alcohol exposure and poor obstetric outcomes, however.²⁹ These studies suggest mechanisms such as altered gene expression, oxidative stress, and apoptosis (programmed cell death).³⁰

Warren, Hewitt, and Thomas describe how intrauterine alcohol exposure interferes with the function of L1CAM, the L1 cell-adhesion molecule.³¹ They noted that just one drink could interfere with the ability of L1CAM to mediate cell adhesion and axonal growth. Prenatal alcohol exposure is also thought to contribute to interference in neurotransmitter and N-methyl-D-aspartate receptor coupling, which may have potential therapeutic implications.³²

Considerations in FAS identification and treatment

There is a potential to identify alcohol exposure in the womb. The majority of ingested alcohol is eventually converted to carbon dioxide and water in both maternal and fetal circulations, which has hampered the identification of biomarkers for clinical use in FAS. Fatty acid ethyl esters (FAEEs), nonoxidative metabolites of ethanol, may prove to be such markers.³³ FAEEs have been measured in a variety of tissues, including blood and meconium. FAEEs can be measured in both neonatal and maternal hair samples.

A study evaluating the utility of such testing in 324 at-risk pregnancies revealed 90% sensitivity and 90% specificity for identifying “excessive drinking” using a cutoff of 0.5 ng/mg.³⁴

Research shows potential therapeutic approaches during pregnancy. While the use of biomarkers has the potential to assist with the identification of at-risk newborns, it merely identifies past alcohol use; it doesn’t necessarily permit identification and prevention of the known negative pediatric sequelae. Preliminary animal studies reveal the potential benefit of neuroprotective peptides to prevent brain damage in alcohol-exposed mice.³⁵ Further research is ongoing.

Treatment: The earlier the better

Early diagnosis and a positive environment improve outcomes. It is well established that early intervention improves outcomes. One comprehensive review of 415 patients with FAS noted troubling outcomes in general for adolescents and adults.³⁶ Over their life spans, the prevalence of such outcomes was:

• 61% for disrupted school experiences
• 60% for trouble with the law
• 50% for confinement (in detention, jail, prison, or a psychiatric or alcohol/drug inpatient setting)
• 49% for inappropriate sexual behaviors on repeated occasions
• 35% for alcohol/drug problems.

The odds of escaping these adverse life outcomes are increased up to fourfold when the individual receives a FAS or FASD diagnosis at an earlier age and is reared in a stable environment.³⁶

 

Barrier to treatment: A mother’s guilt. One of the challenges I’ve learned from my sister-in-law is the stigma mothers face when they bring their child in for services once the diagnosis of FAS is suspected. While adoptive mothers obviously can’t be held accountable for the intrauterine environment to which a fetus is exposed, the same can’t be said of biologic mothers. Therefore, there is a real risk that a mother who is unwilling or unable to face the potentially devastating news that her baby’s issues might be related to choices she made during pregnancy, might not bring her child in for necessary assessment and treatment. Therefore, prevention is a key proponent of treatment.

Prevent FAS: Provide contraception, screen for alcohol use, intervene

While ObGyns aren’t likely to diagnose many children with FAS, we are in an excellent position to try to prevent this tragedy through our counseling of reproductive-aged women. I suspect that most obstetricians spend a considerable amount of time discussing much less frequent obstetric sequelae, such as listeriosis, in the prenatal care setting. Validated alcohol screening tools take moments to administer, and once patients who might have alcohol problems are identified, either a serious discussion about contraception or an honest discussion of FAS may be appropriate. There have been a number of screening tools developed.

The CAGE screen is frequently taught in medical schools, but it isn’t as sensitive for women or minorities.¹⁹

The T-ACE (Tolerance, Annoyed, Cut Down, Eye-opener) tool involves four questions that take less than 1 minute to administer (FIGURE 1).³⁹

TWEAK is another potential tool identified by Russell and colleagues (Tolerance, Worry, Eye opener, Amnesia, and Cut down in drinking).³⁹ Other methods utilized include an AUDIT screen and a CRAFFT screen.⁴⁰ Regardless of which tool is utilized, screening is not time-consuming and is better than merely inquiring about alcohol consumption in general.

FIGURE 1 T-ACE validated alcohol screening tool
Source: American College of Obstetricians and Gynecologists. At risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008;112(6):1449–1460.

When alcohol use is found, intervene

Once patients with at-risk behavior are identified, obstetric staff should offer brief interventions to influence problem drinking. Miller and Sanchez summarized the key elements that were most successful in these programs with the acronym FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy (FIGURE 2).⁴¹ This approach has been formally evaluated in the CDC’s multisite pilot study entitled Project CHOICES.⁴²

In this motivational intervention, sexually active, fertile women of reproductive age underwent up to four motivational counseling sessions and one visit to a provider. At 6 months, 69% of women reduced their risk for an alcohol-exposed pregnancy—although the women who drank the least amount had the greatest benefit, primarily by choosing effective contraception, but also by reducing alcohol intake.

FIGURE 2 FRAMES model to deliver brief interventions
Source: American College of Obstetricians and Gynecologists. Drinking and reproductive health: A fetal alcohol spectrum disorders prevention tool kit. Washington, DC: ACOG; 2006.

A single, brief intervention is effective in already-pregnant women. Chang and colleagues conducted a randomized trial of a single-session brief intervention given to pregnant women with positive T-ACE screens and their partners (FIGURE 3).⁴³ Either the study nurse or physician participated in the intervention, and each single session took 25 minutes on average. The pregnant women with the highest level of alcohol use reduced their drinking the most, and this effect was even larger when their partners participated. Other studies of brief interventions showed similar benefits.^44,45

Another study evaluating a brief intervention involving training of health-care providers to improve screening rates revealed improved detection and therapy among at-risk patients.⁴⁶

FIGURE 3 Single session, 25-minute intervention for patients and their partners
Source: Chang G, McNamara T, Orav J, et al. Brief intervention for prenatal alcohol use: a randomized trial. Obstet Gynecol. 2005;105(5 Pt 1):991–998.

FAS prevention begins with routine counseling and contraception

Although FAS is often thought of in relation to obstetric populations, appointments for preconception counseling or routine health maintenance among women of reproductive age are an essential tool in FAS prevention. As previously mentioned, since approximately half of all pregnancies in this country are unplanned, long-acting reversible contraception is widely available to facilitate improved family planning.

Other contraceptive options also should be discussed. ACOG has teamed up with the CDC to develop a phone app for providers to use at the patient’s bedside to assist with identification and treatment of women at risk for alcohol use during pregnancy.⁴⁷

The stakes are high, it’s time to step up

 

As obstetricians, we are powerless to prevent many conditions—such as vasa previa, acute fatty liver of pregnancy, and amniotic band syndrome. FAS is 100% preventable.

There aren’t that many proven teratogens in our profession, and there are none that involve behavior that is more socially acceptable than alcohol consumption. It is time for our profession to encourage women to appreciate how small a percentage of one’s life is spent pregnant, how many more years there are to enjoy an occasional cocktail, and how very high the stakes are during this important period of their lives. Oh, how I wish someone had been able to communicate all of this to sweet Charlie’s biologic mother. I am so grateful he’s getting the exceptional care he’s getting and very optimistic regarding his future. I only hope others in his situation are given the same opportunities.

We want to hear from you! Tell us what you think.