Fetal Alcohol Syndrome A Review and Case Presentation

principles and practice Fetal Alcohol Syndrome A Review and Case Presentation ELENA LINDOR, RN, ANNE-MARIE MCCARTHY, RN, BS, a n d MAUREEN GUARINO McRAE, RN, MS

rfuifiei

of !he lilerature on the fetal alcohol syndrome

(FAS) is presented. Potentid risks to the

oyspring in response to maternal alcohol ingestion are described. A case presentation, including both malfrnal and infant problems, emphasizes the physical, as well as emotional, aspects of care when FAS ix anlicipaled prenatal(y or is encountered in the clinical setting. Recommendationsf o r education and counseling are also discussed.

Recent literature has drawn the attention of the maternal-child professional to the fetal alcohol syndrome and to the fact that maternal alcohol ingestion may result in devastating, irreversible effects to the fetus. While we continue to explore findings to guide our counseling interventions for these women, many research questions remain unanswered: How do the risks apply to the offspring of the rare, social, moderate, and heavy drinker? At what stage of pregnancy is alcohol ingestion most harmful? Finally, how can n u r s i n g interventions a l t e r t h e course of fetal outcome in the pregnant woman? Review of the Literature

T h e suspicion that alcohol has an adverse effect on fetal development has been with us since ancient times. In Carthage, drinking was prohibited on the wedding night for fear of producing a defective child. An 18th century report to the English parliament noted that children of alcoholic mothers often had a starved and shriveled look, and in 1800 Sullivan reported a high incidence of perinatal mortality in the offspring of 120 drunkards in a Liverpool jail.’ It is both appalling and unfortunate

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that these warnings were not heeded until recent times. In fact, as late as the 1940s and 1950s, government rep o r t s a n d books o n p r e g n a n c y claimed that there were no known ill effects of alcohol to the fetus.’ In 1968, Lemoine’ described a pattern of pre- and postnatal growth deficiency, developmental delay, mental retardation, microcephaly, and facial, limb, and cardiac defects, and attributed these characteristics to the effects of alcohol in utero. These observations were neglected until 1973 when Jones, et al.,’ coined the term “fetal alcohol syndrome” (FAS) . Jones’ reported a study of eight unrelated children of three different ethnic groups who showed a similar pattern of anomalies and who all were born to mothers who were chronic alcoholics. Later, in 1973, Jones’ further confirmed the immutable nature of the prenatal onset growth deficiency of FAS by describing abnormalities in three more offspring of alcoholic mothers, By April 1976, Jones, et al.,” had identified a total of 41 patients with fetal alcohol syndrome. While it is known that ethanol freely crosses the placental barrier, it is still not known whether it is the alcohol or the breakdown products of

alcohol t h a t cause t h e d a m a g e . There is a possibility that alcohol itself may not harm the fetus, but that the breakdown product acetaldehyde is cytotoxic and teratogenic at blood levels over 35 pmol/l.” While blood levels of acetaldehyde in healthy, .people . do not normally exceed 30 pmol/l after alcohol, individuals with a n inhcrited or acquired defect ,f mitochondrial aldehyde dehydrogenase m a y h a v e acetaldehyde levels well Over the danger l i m i t even after modest alto. hol intake.”

This may explain why some women may have adverse effects from just “social d r i n k i n g ” , w h i l e some women who are heavy drinkers may have normal babies. Research indicates that alcoholic mothers who drink heavily during pregnancy risk physical and mental deficiency in their offspring, and that even social drinking may have detrimental effects on the birthweight and behavior of infants.’ While studies suggest that structural damage occurs during the first trimester,’ pilot observations show that a decrease in alcohol consumption during the third trimester of pregnancy lowers the risk to the offspring, suggesting that “since late gestation is the period when adverse factors have the greatest effect on fetal growth, cessation or marked reduction of alcohol consumption may facilitate growth and functional development.’” (See Table 1.) Preliminary data from the National Institute of Neurological Disease and Stroke indicate a 43% incidence of FAS in offspring of women whose alcoholism was ascertained during pregnancy; 44% have mental deficiency, 17% have perinatal mortality.8 O n e study, limited to a distinctive population of white middle class women, reported t h a t daily con~July/Auqust IO80JOCN Nursing

0090-03 1 l/8O/O7 17-0222I6OIOO

Recognizing Fetal Alcohol Syndrome in the Nursery

sumption of one ounce of absolute alcohol before pregnancy is associated with a decrease in birthweight of 91 grams. O n e ounce daily in late pregnancy is associated with a decrease in birthweight of 160 grams.’ In his study of eight children of DOROTHY BAKTIXTT, KN, MS and AGNES DA VIS, KN, BS chronic alcoholics, Jones4 identified pre- and postnatal growth deficiency, noting that after one year, Thc proh/eni of recognizifi~y fclal alcohol syndrome in thc nurscry, espccia f l y when /he possrhrlzty o/ the average rate of weight gain was FAS has no1 bwn anticipatrd, I.$ addressed. A nursing care plan is prcscn!ed. only 38% of normal and the average growth rate was 65% of normal. Jones also found that the head cirT h e recognition of the Fetal Alco- and epicanthal folds. These infants cumference at birth in 7 of the 8 hol Syndrome (FAS) in the newborn also had abnormal palmar creases. children was below the third per- often depends on the astuteness of Results of chromosome studies were centile for gestational age and that the nursery staff since the alcohol not abnormal. in performance testing none of the use of the mother is, most often, not In a neonate with clear-cut clinichildren were within the normal previously known and the nurse is cal features of FAS, there is a charrange. usually involved in the admission of acteristic irritability which may be In measuring the palpebral fissure the infant to the nursery. It is at this part of a withdrawal reaction.’ In length in the same children, Jones time that observation leads to direct- 24-48 hours, our infants exhibited found that the eye was frequently ing the physician’s attention to the tremors and irritability; three had abnormal, with short palpebral fis- baby. These infants a r e usually spontaneous seizures and assumed sure interpreted as being secondary brought to a Newborn Intensive o p ist ho t on ic postures for va r ia b I e to microphthalmus. Occasionally, Care Unit (secondary or tertiary lengths of time. (Adult alcoholics in cataract and retinal abnormalities care) because they may be growth withdrawal also show symptoms of were observed. retarded, niay manifest various ab- irritability, t remors, arid soirictinies Joint and skeletal anomalies, al- normalities, or may exhibit symp- a lowered threshold for seizures.) terations in joint mobility, and posi- toms much like drug withdrawal. As the infants manifested irritabiltioning in hands, elbows, hips, and ity and tremors, a diagnostic workfeet could be related to neurological Encountering FAS u p was initiated which included impairment of the fetus, including In a two-year period at T h e Jew- spinal tap and determinations of calreduced movement. This is further ish Hospital and Medical Center of cium, blood glucose, serum elecimplied by the altered palmer flex- Brooklyn, six infants in the Newborn trolytes; the results of all of these ion crease patterns which are nor- Intensive Care Unit (NICU) were tests were within nornial limits. mally determined by 11 weeks’ ges- seen with classic dysmorphic fea- Drug abuse by one mother was sustation. pected, although urine collected tures of FAS. Other abnormalities and anomaThough 5 of the 6 infants were from the infant for toxicology was lies which have been identified occur born at term, the length and weight found to be negative. Abdominal in unpredictable frequency and not was under the 10th percentile; one distention was also noted in these inall characteristics are found in every infant born at 34 weeks’ gestation fants, but x-rays did not reveal any child. (See Appendix for a complete was also underdeveloped, being un- abnornialitics. list.) Many anomalies are still unex- der the 25th percentile by length T h e mothers o f these infants were plained as is the predictability of the and weight. T h e infants also had difficult to interview about their aldamage of alcohol to the unborn small head sizes (under the 10th per- cohol intake; most finally admitted fetus. centile b y circumference). the faces to a fairly liberal use of alcohol for a had short palpebral fissures, micro- long time. All had appeared to have Maternal Case Presentation gnathia, low nasal bridges, long con- alcohol on their breath at delivery, T h e patient was a 30-year-old di- vex upper lips (a fish-mouth appear- and during the sporadic visits to vorced woman, gravida three, para ance), narrow verniillion borders, their infants in the nursery sonic one, one spontaneous abortion, who July/August 1980JOCN Nursing

00%-03I I /80/07 17-0223$0 100

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were noted by the nursing staff to be ntoxicated by alcohol. O n e mother jelivering two infants with FAS apiroximately one year apart actually ibandoned these infants and was iot seen to visit the nursery services. 3nly one mother admitted to drug 3buse two years prior to her pregiancy. Five of these mothers had no Irenatal care and one had only one xenatal visit prior to her delivery. Infants with FAS have a higher ncidence of perinatal mortality.’ rhese infants, born small for gestaional age, also remain growth rearded through life.’ Studies by !ones, et al.” show them also to be developmentally and intellectually eetarded. In studies on chick emxyos developing in an alcoholic environment, brain cell disxganization was seen’”;Jones’.” also i e s c r i b e d b r a i n s t r uc t u r e d isIrganization in an autopsy on an inrant with FAS.

should be transferred to a secondary or tertiary care unit or at least observed very carefully during the first week of life. T h e pediatrician should be notified immediately so that a diagnostic work-up can be initiated, and the social service worker should be involved early in planning for the infant’s eventual discharge and follow-up plan. T h e following is an outline of a nursing care plan to follow the infant with FAS in the nursery service.

A. In the first 48 hours of life

Infants are born small-for-gestational age 1. Nursing care plans would be similar to caring for a lowbirthweight b a b y (environmental care). 2. Observe for hypoglycemia common in low-birthweight infants, monitor blood glucose with heel stick blood and Dext rostix.@. Nursing Care Plan 3. Internal malformations may be suspecteddspecially cardiac; Nursery nurses should familiarize observe for c a r d i a c failure themselves with the features of FAS (tachypnea, tachycardia, diffibecause, often, initial diagnosis deculty in feeding, etc.). pends on recognizing these features. 4. Strap immediately for first Not all mothers are willing to discuss sample of urine; refrigerate their habits, or they may not feel sample and save for toxicologic they are ingesting sufficient alcohol analysis. to cause any damage to themselves (one or two cocktails nightly or Infant exhibits “withdrawal whenever depressed) and certainly symptoms” not to the fetus. T h e nursing staff 1. Observe especially for seizureshould note whether the mother had like activity and be prepared to alcohol on her breath at delivery or give nursing care. d u r i n g t h e n u r s e r y visits; t h e y 2. Note whether abdominal disshould note whether the mother aptention occurs; watch for regurpears to visit the infant only sporadigitation, stooling pattern, etc. c a l l y ; a n d t h e y s h o u l d also b e 3. Place in less stimulating envialerted by the mother who has a ronment (low light, quiet, etc.). poor self-care concept and has not 4. Medication-not well estabattended prenatal clinics or has done lished, however make ready so only very infrequently. She may chlorpromazine (2 rng/kg/d in also exhibit belligerent behavior at divided dose) or phenobarbital times when visiting her infant and (5-8 mg/kg/d in divided dose). may even be abusive to the staff. 5. Help physician with diagnostic Infants exhibiting FAS features work-up: spinal t a p , blood admitted to primary care nurseries

drawing for electrolytes, sugar, EKG for Q o T C for calcium.

B. In thefirst week of lge Growth retardalion Note adequate nutrition (120 cal/ kg/day).

Persistent tremors, irritability, opislhotonic posture Make comfortable, place in lowstimulus environment.

C. Mother-Infant Interaction Engage mother in in-depth interview regarding her 11festyle Determine extent of alcohol use, note any lack of self-care concepts in mother, poor visiting patterns, signs of intoxicat ion, belligerence.

NoliSy Social Service worker Frequent discussions with social worker and physician in patient care conferences.

Mother-infant inferaction 1 . Encourage mother’s visiting,

help in care of infant. 2. Explain alcohol’s effects on infant and future pregnancies.

Long-term follow-up 1. Help in family planning counseling. 2. Encourage planning for clinic care for mother and infant. 3. Encourage mother to apply to detoxification program. 4. If needed, help in planning for infant’s placement. It may be difficult to convince the chronic drinker to give u p her habit. She may actually abandon the child, may never be motivated to use family planning methods, and may not avail herself of prenatal visits, especially if she is a n alcoholic. The management of a child born to a heavy drinking or chronic alcoholic mother presents a serious challenge to the medical community.

Table 1. Relation Between Clinical Status of Offspring of Heavy Drinking Women and Change in Alcohol Consumption Before Third Trimester. Abstained or Reduced Drinking (N = 15)

Acknowledgments We thank S. Pierog, MD, for her support to the nursing staff a n d help in reviewing this manuscript.

References I. Pierog S, Chandavasu 0, Wexler I: W i t h d r a w a l symptoms in infants w i t h the fetal alcohol syndrome. J Pediatr W937-941, 1977 2. Hanson JW, Jones KL, Smith, D W : Fetal alcohol syndrome: Experience with 41 patients. J A M A 235:1458,

1976 3. Jones KL, Smith D W : Recognition of the fetal alcohol syndrome in early infancy. Lancet 2999, 1973 4. Jones KL, Smith D W , Ulleland CN, Streissguth AP: Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1:1267, 1973 5. Sandor S: The influence o f aethyl-alcohol on t h e development o f t h e chick embyro. Rev Roum Embryol Cyt Ser Embryol 5:51, 1968 a 6. Sandor S: The influence of aethyl-alcohol on the developing chick embryo. Rev Roum Embryol Cyt Ser Embryol 5:167, 1968 b

Address for correspondence: Agnes Davis, R N , Obstetrical Department, Jewish Hospital and Medical Center of Brooklyn, 555 Prospect Place, Brooklyn,

Evaluation of Newborn (total N = 42) Normal Congenital anomalies Major Minor Growth abnormalities Small for gestational age Premature Postmature Head circumference below 10th percentile Weight below 10th percentile Length below 10th percentile Functional abnormalities Jittery Hypotonic Poor suck

Continued Heavy Drinking (N = 27)

NO.

Yo

10

67

2

7

1 0

7

4 7

26

0 0 4 0 0 0 2 0 0

27

NO.

10 7 3

15

37

26

11 4

11 33 41 15

11

41

6 5

22

9

13

Yo

18

~

From Rosett H et a17 with permission. Table 2. lntrapartum Maternal Care Plan for Alcohol Abuser Plan/Nursing Orders Problem 1. Diminished physical and nutritional status secondary to alcohol abuse

2. Lack of knowledge regarding labor and delivery

NY 1 1238.

Dietary consultation arranged by primary nurse Offer foods that appeal to patient Offer between meal snacks Familiarize patient with Labor and Delivery nursing staff Discuss labor and delivery procedures with patient (i.e., anesthesia, breathing techniques)

Encourage verbalization and attempt to zation secondary to denial of compli- clarify misconceptions Consult with psychiatric clinical specialists cations of pregnancy as to helping nurses understand the process of denial

3. Unrealistic expectations of hospitali-

Dorothy Bartlett received her M S in Community HealthJrom Long Island University and a BS from St. J osephi College, Brooklyn, New York. She is assistant supervisor of the Neonatal Intensive Care Level 111 Unit at The lewish Hospital and Medical Center of Brook-

4. Overt denial of potential damage to

infant

lyn.

Agnes Davis is a graduate of The J ewish Hosbital and Medical Center of Brooklyn School of Nursing. She received her B S from St. Francis College, Brooklyn She has been a faculty member at several seminars, was the supervisor in the Neonatal Intensive Care (/nit JUT eight years, and is currently the Nursing Care Coordinator of the Obstetric Department at The lewish Hospital and Medical Center of Brook(vn, New York

~~~~

5. Comprised psychosocial status related to social history and lack of significant support systems

Potential Problems 1 . Withdrawal (DTs) from alcohol

Avoid false reassurance. Consistent communication among all members of health team (nursing. medicine, psychiatry, social service) to be coordinated by primary nurse so that patient is presented consistent information Maintain close communication with social service with regard to discharge planning and community agencies Seizure precautions Observe for jitteriness, restlessness, sudden mood changes

2. Alcohol abuse while inpatient

Monitor visitors who may bring alcohol from outside Reinforce potential risk to unborn baby from alcohol

3. Preparation for cesarean section

Discuss same with patient

~

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Table 3. Nursing Care Plan for Infant of Alcohol Abusing Mother Problem

Plan/Nursing Orders

1. Place on Cardiorespiratory monitor a) Observe closely for increased respiratory distress: 1 . Development of bronchopulmonary dysplasia (BPD) 2. Apnea of prematurity with associated bradycardia b) Associated with neurological damage b) Monitor respiratory status closely with seizure activity c) Resulting from “floppy” epiglottis c) Position on side with neck slightly extended utilizing roll behind back and and small trachea under shoulders. Have suction and 0, (bag and mask) at bedside

1 . Respiratory Distress a) Related to prematurity

2. Difficulty feeding associated with prematurity and/or cleft palate

3. Cardiopulmonary arrests related to tracheal-epiglottal anomalies

4

Altered developmental status associated with microcephaly and grand/mal seizures

5. Maternal denial of abnormalities and potential fetal demise

2. Gavage orally in upright position. Burp well pc. Increase amounts of feedings slowly as condition permits, maintaining adequate calories and hydration Observe for cyanosis and potential aspiration, keep suction ready for use; aspirate nares. PRN 3. Have resusitation equipment at bedside (suction, bag and mask, 0,. endotracheal tube, etc.) Initiate CPR “Stat” and “Code” call. Inform anesthesiology of anomalies which have been encountered with previous intubations 4. Offer appropriate auditory and sensory s t i m u l a t i o n d o not over stimulate

5. Encourage parental visitings and physical contact with infant. Assist them to verbalize their concerns regarding anomalies. Be realistic when discussing infant’s potential for survival and/or future physical, neurological, and emotional development; involve the parents in baby’s care (diapering, holding pc.)

6. Potential skin breakdown due to decreased tone and activity and as related to thin tissue covering coccyx

6. Frequently observe for reddened areas

7. Potential congestive heart failure (CHF)

7. Daily w e i g h t s d e alert to excessive

associated with cardiac abnormality (ventricular septa1 defect)

was admitted to the high-risk maternity unit at 32 weeks’ gestation with the diagnosis of intrauterine growth retardation. A known alcoholic for more than 10 years, the patient had had rnultiple psychiatric and social service interventions in an attempt to manage her problem with alcohol. Past medical history was unremarkable; past reproductive history revealed

226

and bony prominences Position on sheep skin or small water mattress to alleviate pressure

weight gain, presence of edema in face and lower extremities, tachycardia

one full-term pregnancy. She presented a vague social history with no significant supports other than a boyfriend who fathered this baby. The patient sought prenatal care early in her pregnancy, at which time her alcoholic problem was evaluated. She initially expressed a great deal of ambivalence toward the pregnancy but nevertheless chose to continue it, despite counseling about

the risk to the baby due to her daily consumption of several ounces of alcohol and two six-packs of beer and in full knowledge of her option of early termination of the pregnancy. She continued to abuse alcohol for the remainder of her pregnancy, denying the potential for damage to her baby. Nursing goals during this admission included 1) assessment of physical status, 2) assessment of emot i o n a l s t a t u s , 3 ) assessment of alcoholic status, 4) assessment of support systems, 5) assessment of fetal well-being, 6) support and counseling as needed, 7) education about self and infant, and 8) discharge planning-social service referrals as indicated to insure followup. (See Table 2 for the maternal care plan.) N u r s i n g c a r e focused o n explanation of the procedures, estriols, stress testing, and ultrasound evaluation, while trying to establish a relationship of trust with the primary nurse. Attempts to alert the patient to potential fetal demise were relentless. Three days after admission, the evaluation of falling estriols and two consecutive positive oxytocin challenge tests necessitated emergency cesarean section. Infant Case Presentation

A girl baby was delivered by emergency cesarean section at 32 weeks’ gestation, weighing 850 gm. Apgar scores were 1 and 4, and she was in moderate respiratory distress. Intubation was performed with difficulty and she was stabilized in 90% FiO, via hood. An umbilical artery catheter was inserted, and albumin, bicarbonate, and glucose were administered. The infant demonstrated classic visible signs of Fetal Alcohol Syndrome which are summarized in the Appendix. The following characteristics were observed: Small for gestational age (weight, 850 gm; length, 35 cm), microcephalic, thin upper vermillian (lip), hypertelorism, low-set posterior ears, antero-verted nostrils, flat nasal bridge, nail hypoplasia, bilateral July/August 1980JOG“ Nursing

syndactyly feet, absent clitoris, systolic murmur, synactosis R radius ulna, absent phalanx 5th digit R, sluggish pupillary response with cloudy cornea, small cleft palate, small trachea, paper thin epiglottis, prominent coccyx, ventricular septa1 defect. The nursing care for this infant (Table 3) was planned according to the needs for respiratory support and nutrition of premature infants, compounded by the characteristics of the Fetal Alcohol Syndrome, which needed constant assessment and intervention. Care planning by both postpartum and nursery staff focused on working with the mother toward the acceptance of the infant’s abnormalities and prognosis (see # 3 in Table 2 and # 5 in Table 3) and on the ever-threatening sequelae of the potential neurological damage. Conclusion and Evaluation of Care Problems encountered during this phase of hospitalization (See Table 4) centered on the patient’s denial of the obvious abberant physical characteristics of her infant and the poor prognosis. She persisted in planning future goals for her infant. Evidence of neurological damage in the infant became apparent on the third day of life when she developed grand-ma1 seizures; she had a grossly abnormal EEG with no obvious difference between her awake and asleep tracings. Episodes of seizure activity continued one to two times per day in spite of attempted management on Dilantin* and phenobarbital. She required 3-hour gavage feedings, and on the ninth day she had two cardiorespiratory arrests (secondary to floppy epiglottis), the first managed by mask/bag resuscitation, the second necessitating intubation and external cardiac massage. The baby died on the 15th day of life. Autopsy permission was denied. Despite the plans outlined by the nursing staff in attempting to evaluate the purpose of the patient’s denial of the outcome, all attempts failed. She accepted the death of her infant, but attributed the cause of death to prematurity. Attempts to July/August 1980JOGN Nursing

Table 4. Maternal PostpartumCare Plan for Alcohol Abuser

Plan/Nursing Orders ~~

Problem 1. Pain related to surgery 2. Inadequate bonding environment secondary to infant’s physical status

Splint incision, encourage ambulation Encourage visits to Special Care Nursery to hold and care for infant as much as possible

3. Inappropriate expectations related to Emphasis on consistency of information given to patient regarding infant’s prognosis. denial of infant’s poor prognosis Potential Problem 1. Prolonged recovery postoperative phase related to deteriorated physical and nutritional status

Observe closely for signs and symptoms of infection Watch CBC and report significant changes

2. Alcohol abuse during hospitalization

Monitor visitors, if possible, on all shifts

3. Lack of cooperation for follow-up counseling, i.e., contraception, social service

Make appropriate referrals and encourage patient to follow through

foster an acceptance of alcohol as embryotoxic and teratogenic were unsuccessful. Discharge planning included a follow-up visit to psychiatry and social service two weeks after discharge, at which time the patient returned to clinic displaying signs of alcohol intoxication. She continues to be followed by social service and psychiatry on an outpatient basis, although her drinking problems persist. The nursing staff became very much aware that a hospital stay of 7 days could not cure the patient’s physical, emotional, and psychosocial problems. Although a team of interdisciplinary health professionals made every attempt to foster some growth in this patient, we had to face the fact that all of our goals could not be met. Perhaps we should not feel defeated, but should consider the following in caring for such patients. Alcoholism is a complex disease with biological, psychological, and sociological conditions. and

All three levels-biologic,

psychologic, and socialLContribute to the development of alcoholism in a manner which is significant for rational therapeutic intervention, then the description of the extent to which each of these mechanisms contribute to the whole becomes necessary to an understanding of those areas in which appropriate therapeutic intervention can and should be made.”

Conclusion There are many unanswered questions concerning FAS, and many suggest that elective abortion should be an option for a woman who continues heavy drinking during pregnancy. T h e U S . Department of HEW,” in 1978, r e c o m m e n d e d t h a t a woman generally adhere to a twodrink limit per day (no more than 1 oz. of absolute alcohol; 1 oz. alcohol = 2 mixed drinks). While it has been proven that six or more drinks per day is harmful to the fetus, the risk involved when the alcohol ingestion ranges from the two-drink safety zone to the six-drink danger zone is still unknown, and the safety of even two drinks daily is suspect. In view of the data presented thus far, it seems apparent that we have many hurdles to cross before FAS is fully understood and the role of intervention and education can be consolidated for the practitioner. At present time, some criteria seem reasonable: 1. Women must be informed of the risk of taking alcohol during pregnancy. 2. Abstinence from alcohol during pregnancy should be encouraged until further studies prove the effects of alcohol at different states of pregnancy. 3. Counseling of the pregnant alcoholic should focus on abstaining from alcohol. 4. Counseling must keep in mind that studies show that decreasing al-

227

coho1 consumption during the last trimester may prove beneficial if early intervention has failed. 5. No conclusions can be drawn regarding the risks of the amount of alcohol ingestion per day, and therefore, any safety zone is merely conjecture. Alcohol must be placed in the category of drugs to be avoided during pregnancy, and counseling a n d e d u c a t i o n must n o t focus merely on the alcoholic, since even the social drinker or rare drinker is possibly at risk. 6. Alcohol intake must be included in history taking and assessment. If the need for intervention is identified early in pregnancy, the nurse must educate and counsel; depending on the amount of alcohol ingestion since conception, abortion should be an option. 7. When discovery of alcohol abuse is made late in pregnancy, abstinence from alcohol consumption for the remainder of the pregnancy must be encouraged.

3.

4.

5.

6.

7.

8.

9.

10.

References 1. Streissguth A: Maternal drinking and the outcome of pregnancy. Am J Obstet Gynecol 47:422-424, 1977 2. Lemoine P, Haronsseau H, Borteyru JP: Les enfants des parents alcooliques: anomalies observees a propos

11.

de 127 cas. Quest Med 25:476-482, 1968 Jones K, Smith D: Recognition of fetal alcohol syndrome in early infancy. Lancet 2:999-1000, 1973 Jones K, Smith D, Ulleland C, Pytkowcz A, Streissguth A: Patterns of malformation in offspring of chronic alcoholic mothers. Lancet 1:12671271, 1973 Jones K, Hanson J, Smith D: Fetal alcohol syndrome experience with 41 patients. JAMA 235: 1458-1460, 1976 Dunn PM, Stewart-Brown S, Peel R: Metronidazole and the fetal alcohol syndrome. Lancet 2:144, 1979 Rosett H, Ouellette E, Weiner L, Owens E: Therapy of heavy drinking during prgnancy. Obstet Gynecol 51:41-46, 1978 Robinson R: Fetal alcohol syndrome. Dev Med Child Neurol 19:538-540, 1977 Little R: Moderate alcohol use during pregnancy and decreased infant birth weight. Am J Public Health 67:1154-1156, 1977 Kissin B, Begleiler H: The Biology of Alcoholism Treatment and Rehabilitation of the Chronic Alcoholic. Vol. 5. New York, Plenum Press, 1977, pp 1-9 DHEW Publication No. (ADM) 78521, 1978

Supplemental Bibliography Blinick G, Wallach RC, Farey E, et al.: Drug addiction in pregnancy and the

neonate. Am J Obstet Gynecol 125: 135- 142, 1976 Editorial: Fetal alcohol syndrome. Lancet 1:1335, 1973 Luke G: Maternal alcohol and fetal alcohol syndrome. Am J Nurs 77:19241926, 1977 Mulvihill JJ, Klimas JT, Stokes DC, et al.: Fetal alcohol syndrome: Seven new cases. Am J Obstet Gynecol 125:937-941, 1976 Letter: Effects of alcohol on the fetus. N Engl J Med 298:55-56, 1978 Pierog S, Chandavasu 0, Wexler I: Withdrawal symptoms in infants with the fetal alcohol syndrome. J Pediatr 90:937-941, 1977 Qazi A, Masakawa A, Milman D, McGann B, Chua A, Haller J: Renal anomalies in fetal alcohol syndrome. Pediatrics 63:886, 1979

Address for correspondence: Maureen McRae, RN, Ob/Gyn Nursing, Beth Israel Hospital, 330 Brookline Avenue, Boston, MA 02215.

Elena Lindor is head nurse of High Risk Postpartum at Beth Israel Hospital in Boston. Anne-Marie McCarthy is head nurse of the Special Care Nursery at Beth Israel Hospital. Maureen McRae is head nurse of Labor and Delivery at Beth Israel Hospital, where she previously worked as educational coordinator of obstetricallgynecological nursing.

Appendix: COMMON ABNORMALITIES AND OTHER IDENTIFIED DEFECTS IN FETAL ALCOHOL SYNDROME' Common abnormalities of infants born to severe chronic alcoholic mothers

Other defects seen to be less consistent features of the Fetal Alcohol Syndrome

Growth and performance Prenatal growth deficiency Postnatal growth deficiency Microcephaly Developmental delay or mental deficiency Craniofacial Short palpebral fissures Midfacial hypoplasia Epicanthal folds Limb Abnormal palmer creases Joint anomalies Other Cardiac defect External genital anomalies Hemingiomas Ear anomalies

Craniofacial Anomalies Microphthalmus lntraocular defects Strabismus Ptosis of eyelids Cleft palate Musculoskeletal Anomalies Pectus exacavatum Diaphragmatic anomalies Small nails Cutaneous Anomalies Pigmented nevi Hirsutism

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