It should be assumed that pregnant women who consume over 8 ounces of [absolute] alcohol (1 pint of liquor) daily have developed tolerance.12 However, tolerance may develop at lower levels of consumption in some women and in women using multiple drugs.
The sudden cessation of drinking can result in withdrawal symptoms, some of which may be threatening to the mother and the fetus.
It is imperative that medical withdrawal of an alcohol-dependent, pregnant woman be conducted in an inpatient setting and under medical supervision that includes collaboration with an obstetrician.
These conditions will ensure
Close observation and monitoring of maternal alcohol withdrawal status
Continual monitoring of fetal well-being
Most programs choose to treat the pregnant, alcohol-dependent woman with short-acting barbiturates or benzodiazepines.
Chlordiazepoxide (Librium) and other benzodiazepines, such as diazepam (Valium) and barbiturates (Phenobarbital, Seconal), are valuable for symptomatic treatment during medical withdrawal from alcohol.
They are also potentially teratogenic.
Some clinicians, therefore, recommend avoiding their use if at all possible.
The risks versus the possible benefits of their use need to be assessed.
Disulfiram (Antabuse) is contraindicated during pregnancy.
Its use has been associated with clubfoot, VACTERL syndrome (a pattern of congenital anomalies), and phocomelia of the lower extremities.13 The woman who conceives while taking this drug should receive counseling before deciding to continue the pregnancy.
Symptoms of Alcohol Withdrawal
Early symptoms of alcohol withdrawal generally appear 6 to 48 hours after drinking has stopped but can occur up to 10 days after the last drink.
Withdrawal symptoms may include
Restlessness
Tachycardia
Irritability
Hypertension
Anorexia
Insomnia
Nausea
Nightmares
Vomiting
Impaired concentration
Sweating
Impaired memory
Tremor
Elevated vital signs
More severe symptoms of alcohol withdrawal may include
Increased tremulousness
Increased agitation
Increased sweating
Delirium (with confusion, disorientation, impaired memory and judgment)
Hallucinations (auditory, visual, or tactile)
Delusions (usually paranoid)
Grand mal seizures
Note: Withdrawal symptoms do not necessarily progress from mild to severe.
In some individuals, a grand mal seizure may be the first sign of withdrawal.
Seizures usually occur 12 to 24 hours after cessation or reduction of drinking.
One-third of all patients who have seizures develop delirium tremens.
1 Evaluate the pattern, frequency, and amount of alcohol and other drug use.
2 Obtain a detailed history of alcohol and other drug use within the past 24 hours and of any previous alcohol withdrawal reaction.
3 Begin initial treatment with thiamine, folic acid, and prenatal iron and vitamins.
Obtain laboratory tests listed above, including CBC, electrolytes, and magnesium level and, when indicated, obtain an electrocardiogram (EKG).
4 Obtain an initial blood alcohol level to determine
Extent of intoxication at admission
Safe time to begin medication
Expected time for full withdrawal to begin.
The usual rate of elimination of alcohol from a healthy alcohol dependent person is 30 mg/dl/hr.
This rate may be increased during pregnancy.
5 Provide for nonpharmacological interventions designed to
Reduce stimuli
Maintain hydration
Maintain reality orientation
Provide reassurance and positive reinforcement
Provide nutritional support
Maintain physical comfort
Maintain body temperature
Encourage sleep and rest
6 Follow withdrawal schedule.
Programs use different drugs to withdraw patients from alcohol.
Drugs used include chlordiazepoxide, phenobarbital, and diazepam.
Typical withdrawal schedules using chlordiaze-poxide include 25 to 50 mg 4 times a day for the first 2 days, decreasing gradually to 10 mg 4 times a day for days 8 through 10.
Typical withdrawal schedules using phenobarbital include 15 to 60 mg by mouth every 4 to 6 hours as needed for the first 2 days, decreasing gradually to 15 mg by the 4th day.
Typical withdrawal schedules using diazepam include 10 mg 4 times a day; 10 mg every 2 hours as needed for withdrawal symptoms with a maximum of 150 mg/24 hours; decreasing gradually at a rate of 20 to 25 percent over approximately 5 days.
The loading dose protocol with diazepam is accomplished with doses given according to withdrawal symptomatology.
When withdrawal symptoms are stabilized, the long half-life of diazepam alleviates the need for further medication in most cases.
7 Monitor for signs and symptoms of alcohol withdrawal syndrome (AWS).
The use of withdrawal assessment scales can be valuable in determining the need for further medication.
Monitor for the following:
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